1649568288 NPI number — DR. GOPI KIRAN MAHARAJA MD

Table of content: DR. GOPI KIRAN MAHARAJA MD (NPI 1649568288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649568288 NPI number — DR. GOPI KIRAN MAHARAJA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAHARAJA
Provider First Name:
GOPI
Provider Middle Name:
KIRAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
U

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649568288
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 878
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33836-0878
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
689-223-3898
Provider Business Mailing Address Fax Number:
689-223-3898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 PARK PLACE BLVD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33837-6868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-588-4775
Provider Business Practice Location Address Fax Number:
863-422-7664
Provider Enumeration Date:
07/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  ME12604412 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 021225800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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