Healthcare Provider Details

I. General information

NPI: 1366409195
Provider Name (Legal Business Name): GOPIKA MYNENI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: GOPIKA SUNKAVALLI M.D.

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12368 STRATFORD DR SUITE 300
CLIVE IA
50325-8162
US

IV. Provider business mailing address

12368 STRATFORD DR SUITE 300
CLIVE IA
50325-8162
US

V. Phone/Fax

Practice location:
  • Phone: 515-226-9810
  • Fax: 515-226-8408
Mailing address:
  • Phone: 515-226-9810
  • Fax: 515-226-8408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35237
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2460584
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: