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General NPI Number Information
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NPI Number | 1467866129
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Entity Type | Individual
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Provider Name | RAVI VARMA GOTTUMUKKALA M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/19/2014
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Last Update Date | 05/08/2019
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Provider Practice Location Address
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Address Line | 55 FRUIT ST. RADIOLOGY
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City | BOSTON
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State | MA
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Zip | 02114
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Country | US
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Telephone | 630-291-9085
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Fax |
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Provider Business Mailing Address
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Address Line | 4 LONGFELLOW PL APT 2009
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City | BOSTON
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State | MA
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Zip | 02114-2817
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Country | US
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Telephone | 630-291-9085
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 273231
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License Number State | MA
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