Provider Demographics
NPI:1336168574
Name:GOPAL, BHARAT (MD)
Entity type:Individual
Prefix:
First Name:BHARAT
Middle Name:
Last Name:GOPAL
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 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3517 NW SAMARITAN DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3767
Practice Address - Country:US
Practice Address - Phone:541-768-5142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105668207Q00000X
ORMD170577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH54484Medicare UPIN
IL6497860011Medicare NSC
ILIL3270182Medicare PIN