Healthcare Provider Details

I. General information

NPI: 1871173153
Provider Name (Legal Business Name): GOWTHAMRAM RAJAPRABHAKARAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 MARKET ST
WILMINGTON NC
28403-1221
US

IV. Provider business mailing address

PO BOX 96191
CHARLOTTE NC
28296-6191
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-3642
  • Fax: 770-962-3643
Mailing address:
  • Phone: 770-962-3642
  • Fax: 770-962-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20A24131
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2026-03043
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: