Provider Demographics
NPI:1265936827
Name:CHENNU, GOUTHAMI RATNA
Entity type:Individual
Prefix:
First Name:GOUTHAMI
Middle Name:RATNA
Last Name:CHENNU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LYONS AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112
Mailing Address - Country:US
Mailing Address - Phone:973-926-7425
Mailing Address - Fax:973-926-6130
Practice Address - Street 1:201 LYONS AVENUE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112
Practice Address - Country:US
Practice Address - Phone:973-926-7425
Practice Address - Fax:973-926-6130
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2025-06-14
Deactivation Date:2018-03-20
Deactivation Code:
Reactivation Date:2018-03-27
Provider Licenses
StateLicense IDTaxonomies
VA0101285139207RC0000X, 207RI0011X
390200000X
NJ25MA1102000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program