Provider Demographics
NPI:1710118435
Name:PUTTASWAMYGOWDA, VISHWANATH VALAGEREHALLY (MD)
Entity Type:Individual
Prefix:DR
First Name:VISHWANATH
Middle Name:VALAGEREHALLY
Last Name:PUTTASWAMYGOWDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6914 41 ST AVE
Mailing Address - Street 2:UNIT C1
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:718-308-6918
Mailing Address - Fax:718-803-2434
Practice Address - Street 1:6914 41 ST AVE
Practice Address - Street 2:UNIT C1
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:718-308-6918
Practice Address - Fax:718-803-2434
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY223041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03260455Medicaid