Provider Demographics
NPI:1679525505
Name:GOTANCO, RAYMOND J (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:J
Last Name:GOTANCO
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 1:8450 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1381
Mailing Address - Country:US
Mailing Address - Phone:317-802-2000
Mailing Address - Fax:317-802-2170
Practice Address - Street 1:8450 NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1381
Practice Address - Country:US
Practice Address - Phone:317-802-2000
Practice Address - Fax:317-802-2170
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055908A207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200383310Medicaid
INP00336041Medicare PIN
INP00920835Medicare PIN
IN267030DDMedicare PIN
IN165460JJJJMedicare PIN
IN200383310Medicaid