Basic Information
| Provider Information | |||||||||
| NPI: | 1851302137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVAKARA MURTHY | ||||||||
| FirstName: | GOWDARA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 TROY SCHENECTADY RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121102461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187823700 | ||||||||
| FaxNumber: | 5187823799 | ||||||||
| Practice Location | |||||||||
| Address1: | 2546 BALLTOWN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SCHENECTADY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123091079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183741444 | ||||||||
| FaxNumber: | 5183740491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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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 | 207R00000X | 208468 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03299543 | 05 | NY | MEDICAID | 7795243 | 01 | NY | AETNA | OTHER | 781CB1 | 01 | NY | EMPIRE BLUECROSS BLUESHIELD | OTHER | 130712000045 | 01 | NY | FIDELIS | OTHER |