Healthcare Provider Details

I. General information

NPI: 1992891972
Provider Name (Legal Business Name): GURUSHANKAR GOVINDARAJAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 W HIGH ST
BRYAN OH
43506-1681
US

IV. Provider business mailing address

442 W HIGH ST
BRYAN OH
43506-1681
US

V. Phone/Fax

Practice location:
  • Phone: 419-636-4517
  • Fax: 419-636-6438
Mailing address:
  • Phone: 419-636-4517
  • Fax: 419-636-6438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT2005021696
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-094289
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: