Provider Demographics
NPI:1053473090
Name:GONAVARAM, PARTHA (MD)
Entity Type:Individual
Prefix:DR
First Name:PARTHA
Middle Name:
Last Name:GONAVARAM
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 1:200 S MANCHESTER AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3219
Mailing Address - Country:US
Mailing Address - Phone:714-456-2986
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92697-5036
Practice Address - Country:US
Practice Address - Phone:949-824-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047232207Q00000X
CAC174846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8473399Medicaid
WAI69545Medicare UPIN
WA8863581Medicare PIN