Basic Information
| Provider Information | |||||||||
| NPI: | 1720089139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOKULA | ||||||||
| FirstName: | RADHARAMANAMURTHY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2230 W LASKEY RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436133543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192141213 | ||||||||
| FaxNumber: | 4192140783 | ||||||||
| Practice Location | |||||||||
| Address1: | 2230 W LASKEY RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436133543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178960360 | ||||||||
| FaxNumber: | 4198850203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35089833 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4643573 | 05 | MI | MEDICAID |