Provider Demographics
NPI:1861437428
Name:KORUPOLU, GOPAL R (MD)
Entity type:Individual
Prefix:DR
First Name:GOPAL
Middle Name:R
Last Name:KORUPOLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 15781
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-0124
Mailing Address - Country:US
Mailing Address - Phone:352-799-3449
Mailing Address - Fax:352-799-3214
Practice Address - Street 1:12204 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2630
Practice Address - Country:US
Practice Address - Phone:352-799-3449
Practice Address - Fax:352-799-3214
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0070951207U00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007336200Medicaid
FLG37704Medicare UPIN
FL007336200Medicaid