Provider Demographics
NPI:1992891972
Name:GOVINDARAJAN, GURUSHANKAR (MD)
Entity type:Individual
Prefix:
First Name:GURUSHANKAR
Middle Name:
Last Name:GOVINDARAJAN
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 1:442 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1681
Mailing Address - Country:US
Mailing Address - Phone:419-636-4517
Mailing Address - Fax:419-636-6438
Practice Address - Street 1:442 W HIGH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1681
Practice Address - Country:US
Practice Address - Phone:419-636-4517
Practice Address - Fax:419-636-6438
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT2005021696207R00000X
OH35-094289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00800474OtherRAILROAD
OH4281532Medicare PIN
OH4281534Medicare PIN
OH4281533Medicare PIN