Basic Information
| Provider Information | |||||||||
| NPI: | 1043285232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOWDA | ||||||||
| FirstName: | PRASHANTH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10069 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924230069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093354188 | ||||||||
| FaxNumber: | 9094783644 | ||||||||
| Practice Location | |||||||||
| Address1: | VA LOMA LINDA HEALTH CARE SYSTEM | ||||||||
| Address2: | 11201 BENTON ST | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036113148 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 036113148 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | C55692 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 036113148 | 05 | IL | MEDICAID |