Healthcare Provider Details

I. General information

NPI: 1780676643
Provider Name (Legal Business Name): KRISHNAN A GOPAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 COAL VALLEY RD STE 301
CLAIRTON PA
15025-3730
US

IV. Provider business mailing address

575 COAL VALLEY RD STE 301
CLAIRTON PA
15025-3730
US

V. Phone/Fax

Practice location:
  • Phone: 412-466-7450
  • Fax: 412-466-0588
Mailing address:
  • Phone: 412-466-7450
  • Fax: 412-466-0588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberMD-038578L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier0007104530002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: