Basic Information
| Provider Information | |||||||||
| NPI: | 1073508693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOPAL | ||||||||
| FirstName: | MALAVALLI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 NORTHEASTERN BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030791996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1153 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021303446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175226010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 08/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 38054 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2065053 | 05 | MA | MEDICAID |