Provider Demographics
NPI:1053974071
Name:GOPALAKRISHNAN, SIDDESH (MD)
Entity type:Individual
Prefix:
First Name:SIDDESH
Middle Name:
Last Name:GOPALAKRISHNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-4851
Mailing Address - Country:US
Mailing Address - Phone:888-244-5373
Mailing Address - Fax:
Practice Address - Street 1:2840 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-4851
Practice Address - Country:US
Practice Address - Phone:888-244-5373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA124426002084P0804X, 2084P0800X
CA1825722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry