Provider Demographics
NPI:1215956198
Name:GOPALA, NEDU (MD)
Entity type:Individual
Prefix:MR
First Name:NEDU
Middle Name:
Last Name:GOPALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:NEDUVARAMBAK
Other - Middle Name:
Other - Last Name:GOPALAKRISHNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3250 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-1444
Mailing Address - Country:US
Mailing Address - Phone:812-460-0109
Mailing Address - Fax:812-460-0209
Practice Address - Street 1:3250 N 19TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-1444
Practice Address - Country:US
Practice Address - Phone:812-460-0109
Practice Address - Fax:812-460-0209
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040752207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100384930Medicaid
INF39004Medicare UPIN
IN194960Medicare ID - Type Unspecified