Provider Demographics
NPI:1518164110
Name:THAIYANANTHAN, GOWRIHARAN (MD)
Entity Type:Individual
Prefix:
First Name:GOWRIHARAN
Middle Name:
Last Name:THAIYANANTHAN
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 1:4631 TELLER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8105
Mailing Address - Country:US
Mailing Address - Phone:949-335-7500
Mailing Address - Fax:949-387-1206
Practice Address - Street 1:500 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-468-6937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0059339207T00000X
CAA99924207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1518164110OtherNPI
CAAM707VMedicare PIN
CAAM707XMedicare PIN