Basic Information
| Provider Information | |||||||||
| NPI: | 1124415179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOPARAJU | ||||||||
| FirstName: | KRISHNA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 E HURON ST STE 16738 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129265924 | ||||||||
| FaxNumber: | 3129266134 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2015 | ||||||||
| LastUpdateDate: | 07/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 036.145717 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.