Provider Demographics
NPI:1750367967
Name:GOWDA, BHASKAR (MD)
Entity type:Individual
Prefix:
First Name:BHASKAR
Middle Name:
Last Name:GOWDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BHASKAR
Other - Middle Name:
Other - Last Name:YADURAYAGOWDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15992 TROWBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 PROGRESS PKWY
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2359
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020316422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209022417Medicaid
MO824C545Medicare ID - Type UnspecifiedMEDICARE WEST
MO902931545Medicare ID - Type UnspecifiedMEDICARE EAST
MO209022417Medicaid