Provider Demographics
NPI:1922116672
Name:GOWDA, SHASHIKUMAR R (MD)
Entity Type:Individual
Prefix:
First Name:SHASHIKUMAR
Middle Name:R
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3109
Mailing Address - Fax:812-242-3990
Practice Address - Street 1:1429 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1037
Practice Address - Country:US
Practice Address - Phone:812-242-3109
Practice Address - Fax:812-242-3990
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045040A207RC0200X, 207RP1001X
IL36091244207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01053285OtherRAILROAD MEDICARE
IN200111360SMedicaid
IN200111360XMedicaid
IN200111360OMedicaid
IN200111360Medicaid
INP00834961OtherRAILROAD MEDICARE
000000226195OtherANTHEM
INP00834961OtherRAILROAD MEDICARE
IN200111360SMedicaid
IN841040CCMedicare PIN
IN611880CMedicare PIN
IN192770KKKMedicare PIN
IN130840PMedicare PIN
ILP01053285OtherRAILROAD MEDICARE
IN290015063Medicare PIN
G33144Medicare UPIN
IN200111360Medicaid
IN859920YMedicare PIN
ILP00412105Medicare PIN
IN187310EMedicare PIN
IN265130BBBMedicare PIN