Healthcare Provider Details

I. General information

NPI: 1891995262
Provider Name (Legal Business Name): GANESH GOPALAKRISHNA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR DC018.00, MA202F
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

PO BOX 7687
COLUMBIA MO
65205-7687
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-8006
  • Fax: 573-884-5396
Mailing address:
  • Phone: 573-882-8006
  • Fax: 573-884-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2007010592
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: