Provider Demographics
NPI:1194786137
Name:GOPALAKRISHNAN, THANDAVARAJAN (MD)
Entity type:Individual
Prefix:DR
First Name:THANDAVARAJAN
Middle Name:
Last Name:GOPALAKRISHNAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11721 FUQUA ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77034-4541
Mailing Address - Country:US
Mailing Address - Phone:281-484-3500
Mailing Address - Fax:281-484-3517
Practice Address - Street 1:11721 FUQUA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77034-4541
Practice Address - Country:US
Practice Address - Phone:281-484-3500
Practice Address - Fax:281-484-3517
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5966207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138972802Medicaid
TX138972802Medicaid
TX00648GMedicare ID - Type UnspecifiedINDIVIDUAL ID
TX00506UMedicare ID - Type UnspecifiedGROUP ID