Healthcare Provider Details

I. General information

NPI: 1023148939
Provider Name (Legal Business Name): THOTTATHIL VISWANATHAN GOPAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 45TH ST STE 110
MUNSTER IN
46321-2899
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-3020
  • Fax: 219-922-3023
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number01063174
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: