Basic Information
| Provider Information | |||||||||
| NPI: | 1861428518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTIMUKKALA | ||||||||
| FirstName: | MARUTHI | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 205 BUSINESS PARK DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234626335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579621083 | ||||||||
| FaxNumber: | 7579621254 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 MEDICAL PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233200302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575472233 | ||||||||
| FaxNumber: | 7579621254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 08/12/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 0101041083 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 15848 | 01 | VA | OPTIMA HEALTH PLAN | OTHER | PAR | 01 | VA | FIRST HEALTH COMMERCIAL/SOUTHERN HEALTH/COVENTRY | OTHER | 0604X | 01 | NC | NC BC/BS | OTHER | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER | 1861428518 | 05 | VA | MEDICAID | 295590 | 01 | VA | ANTHEM | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | 187095 | 01 | VA | ANTHEM BC/BS | OTHER | PAR | 01 | VA | CIGNA | OTHER | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | 10015737 | 01 | VA | SENTARA OPTIMA | OTHER | 890604X | 05 | NC | MEDICAID | 010226805 | 05 | VA | MEDICAID | 413773 | 01 | VA | UHC/MAMSI | OTHER | PAR | 01 | VA | AETNA | OTHER | -001 | 01 | VA | TRICARE CHAMPUS | OTHER | 313773 | 01 | VA | MAMSI | OTHER |