Provider Demographics
NPI:1700841798
Name:NAMBUDIRI, GOPAKUMAR S (MD)
Entity type:Individual
Prefix:
First Name:GOPAKUMAR
Middle Name:S
Last Name:NAMBUDIRI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:1629 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-1571
Practice Address - Country:US
Practice Address - Phone:715-307-6430
Practice Address - Fax:715-307-6405
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42583207RH0003X
WI42583-20207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34026800Medicaid
WI0358 20195Medicare ID - Type Unspecified
WI34026800Medicaid