=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760615710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAJA GOPAL SUNKAVALLI M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2009
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 PROFESSIONAL CT STE C
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-8803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-8853
-----------------------------------------------------
Fax | 304-263-6178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 FOUNDATION WAY
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-9000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-264-9202
-----------------------------------------------------
Fax | 304-264-9042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 125055068
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 66329
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 26089
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------