Provider Demographics
NPI:1730133265
Name:GOWDA, KEMPAIAH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KEMPAIAH
Middle Name:A
Last Name:GOWDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:15150 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1302
Mailing Address - Country:US
Mailing Address - Phone:734-282-4800
Mailing Address - Fax:734-282-9302
Practice Address - Street 1:15150 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1302
Practice Address - Country:US
Practice Address - Phone:734-282-4800
Practice Address - Fax:734-282-9302
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037654207RC0000X
MI4301037652207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301037652OtherSTATE LICENSE #
MI1730133265OtherBCBS TYPE 1 NPI #
MI0608201051OtherBLUE CROSS BLUE SHIELD
MI11277306OtherCAQH
MI110007760OtherRR MEDICARE
MI4301037652OtherCDS #
MIB43075OtherHAP
MI0820105OtherBLUE CARE NETWORK
MI1623343Medicaid
MI11277306OtherCAQH
MIP34850003Medicare PIN