Provider Demographics
NPI:1043285232
Name:GOWDA, PRASHANTH (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASHANTH
Middle Name:
Last Name:GOWDA
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:909-335-4188
Mailing Address - Fax:909-478-3644
Practice Address - Street 1:VA LOMA LINDA HEALTH CARE SYSTEM
Practice Address - Street 2:11201 BENTON ST
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-0001
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113148207Q00000X, 207R00000X
CAC55692208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113148Medicaid
ILIL3270568Medicare PIN
IL036113148Medicaid