Basic Information
| Provider Information | |||||||||
| NPI: | 1992891972 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOVINDARAJAN | ||||||||
| FirstName: | GURUSHANKAR | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 442 W HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435061681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196364517 | ||||||||
| FaxNumber: | 4196366438 | ||||||||
| Practice Location | |||||||||
| Address1: | 442 W HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435061681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196364517 | ||||||||
| FaxNumber: | 4196366438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 04/29/2010 | ||||||||
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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 | T2005021696 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35-094289 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00800474 | 01 | OH | RAILROAD | OTHER |