Provider Demographics
NPI:1063403764
Name:SRIDHAR, GOPALAN (MD)
Entity type:Individual
Prefix:
First Name:GOPALAN
Middle Name:
Last Name:SRIDHAR
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 1:555 RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19605-3149
Mailing Address - Country:US
Mailing Address - Phone:610-921-1111
Mailing Address - Fax:610-921-2419
Practice Address - Street 1:555 RAYMOND ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19605-3149
Practice Address - Country:US
Practice Address - Phone:610-921-1111
Practice Address - Fax:610-921-2419
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423219208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100888848Medicaid
PA185771JPUMedicare PIN
PA100888848Medicaid