Provider Demographics
NPI:1194710723
Name:DEREBAIL, GOPALA KRISHNA (MD)
Entity type:Individual
Prefix:DR
First Name:GOPALA
Middle Name:KRISHNA
Last Name:DEREBAIL
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:PO BOX 408
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-0408
Mailing Address - Country:US
Mailing Address - Phone:205-437-6098
Mailing Address - Fax:205-437-5998
Practice Address - Street 1:417 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1943
Practice Address - Country:US
Practice Address - Phone:229-317-2207
Practice Address - Fax:229-317-2214
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014307207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000077316MMedicaid
GA52635244002OtherBCBS
GA000077316QMedicaid
GA364830OtherWELLCARE
GA511I930105OtherGA URGENT CARE MCARE ID
GA52635244-005OtherBCBS
GA000077316TOtherGA URGENT CARE MCAID ID
GA930123518OtherRAILROAD MEDICARE
GA000077316TOtherGA URGENT CARE MCAID ID
GA000077316MMedicaid