Basic Information
| Provider Information | |||||||||
| NPI: | 1316967854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOPURALA | ||||||||
| FirstName: | BALAGANESH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11480 BROOKSHIRE AVE STE 309 | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902415025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628691201 | ||||||||
| FaxNumber: | 5628691281 | ||||||||
| Practice Location | |||||||||
| Address1: | 11480 BROOKSHIRE AVE STE 309 | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902415025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628691201 | ||||||||
| FaxNumber: | 5628691281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 00024965 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | C139871 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 009936594 | 05 | AL | MEDICAID | 009936597 | 05 | AL | MEDICAID | 51534632 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 009936596 | 05 | AL | MEDICAID | 51534631 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | H78600 | 01 | AL | HEALTHSPRING OF ALABAMA | OTHER | 51003582 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | H78600 | 01 | AL | UNITED HEALTHCARE | OTHER | P00314189 | 01 | AL | RAILROAD MEDICARE | OTHER |