Provider Demographics
NPI:1558494690
Name:GOWDA, VINAY B (MD)
Entity Type:Individual
Prefix:
First Name:VINAY
Middle Name:B
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 1457
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-1457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:404-501-5256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59160207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00605278OtherRAILROAD MEDICARE - EASTSIDE
P00698646OtherRAILROAD MEDICARE-DEKALB
GA775076527A- EASTSIDEMedicaid
GA775076527B - DEKALBMedicaid
GA775076527B - DEKALBMedicaid
P00605278OtherRAILROAD MEDICARE - EASTSIDE
GAI05991Medicare UPIN