Provider Demographics
NPI:1962491225
Name:GOWDA, BETTAIAH T (MD)
Entity Type:Individual
Prefix:
First Name:BETTAIAH
Middle Name:T
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 1:5041 UTICA RIDGE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3480
Mailing Address - Country:US
Mailing Address - Phone:563-359-9696
Mailing Address - Fax:563-359-1730
Practice Address - Street 1:5041 UTICA RIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3480
Practice Address - Country:US
Practice Address - Phone:563-359-9696
Practice Address - Fax:563-359-1730
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34119174400000X
IL036096127174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL87985Medicare ID - Type Unspecified
H48158Medicare UPIN
IAI4292Medicare ID - Type Unspecified