Provider Demographics
NPI:1316023559
Name:GOWDAR, PRASANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASANNA
Middle Name:
Last Name:GOWDAR
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 1:741 W PERSHING RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-876-7200
Mailing Address - Fax:217-876-7233
Practice Address - Street 1:741 W PERSHING RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-876-7200
Practice Address - Fax:217-876-7233
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C46216Medicare UPIN
IL737760Medicare ID - Type Unspecified
IL036067549Medicaid