Healthcare Provider Details

I. General information

NPI: 1902045271
Provider Name (Legal Business Name): GOPI KRISHNA RAJU PENMETSA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY HOSPITAL 50 NORTH MEDICAL DRIVE
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

2096 E RAINBOW POINT DR
HOLLADAY UT
84124-1721
US

V. Phone/Fax

Practice location:
  • Phone: 801-803-8728
  • Fax:
Mailing address:
  • Phone: 801-803-8728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number7478485-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: