MEDICARE: DR. PRASHANTH GOWDA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036113148	IL
2	207R00000X	Internal Medicine Physician	036113148	IL
3	208M00000X	Hospitalist Physician	C55692	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043285232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRASHANTH GOWDA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 10069
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92423-0069
Country	:	US
Telephone Number	:	909-335-4188
Fax Number	:	909-478-3644

Provider Business Practice Location Address
First Line	:	VA LOMA LINDA HEALTH CARE SYSTEM
Second Line	:	11201 BENTON ST
City	:	LOMA LINDA
State	:	CA
Zip	:	92357-0001
Country	:	US
Telephone Number	:	909-825-7084
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	09/16/2015

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