Provider Demographics
NPI:1679887988
Name:GOPAL TATAMBHOTLA MD PA
Entity type:Organization
Organization Name:GOPAL TATAMBHOTLA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GOPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:TATAMBHOTLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-527-9500
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34460-0700
Mailing Address - Country:US
Mailing Address - Phone:352-527-9500
Mailing Address - Fax:352-527-7215
Practice Address - Street 1:534 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-8547
Practice Address - Country:US
Practice Address - Phone:352-527-9500
Practice Address - Fax:352-527-7215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME728572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty