Provider Demographics
NPI:1033319199
Name:GONA, PAVAN KUMAR K (MD)
Entity Type:Individual
Prefix:
First Name:PAVAN KUMAR
Middle Name:K
Last Name:GONA
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 1:3615 NW SAMARITAN DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333
Mailing Address - Country:US
Mailing Address - Phone:541-768-6930
Mailing Address - Fax:541-768-6931
Practice Address - Street 1:3615 NW SAMARITAN DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333
Practice Address - Country:US
Practice Address - Phone:541-768-6930
Practice Address - Fax:541-768-6931
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100550207R00000X
ORMD172330207R00000X, 207RN0300X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1005500Medicaid
CAA100550OtherCA MEDICAL LICENSE
CAA100550OtherCA MEDICAL LICENSE
CA00A100551Medicare PIN