Provider Demographics
NPI:1780683953
Name:GOTTUMUKKALA, GANAPATHI (MD)
Entity type:Individual
Prefix:DR
First Name:GANAPATHI
Middle Name:
Last Name:GOTTUMUKKALA
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 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:9660 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9487
Practice Address - Country:US
Practice Address - Phone:193-651-1772
Practice Address - Fax:219-703-6662
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074987207Q00000X
IN01086883A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300057653Medicaid
IL036074987Medicaid
IL01625532OtherBLUE SHIELD PROVIDER #
IL080052428Medicare PIN
IL570900Medicare PIN