Healthcare Provider Details

I. General information

NPI: 1336110402
Provider Name (Legal Business Name): NAGARAJ GOWDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NAGARAJA BANASANDRA RANGEGOWDA M.D.

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY BLVD SUITE 102
JUPITER FL
33458
US

IV. Provider business mailing address

500 UNIVERSITY BLVD SUITE 102
JUPITER FL
33458
US

V. Phone/Fax

Practice location:
  • Phone: 561-622-6610
  • Fax: 561-622-6091
Mailing address:
  • Phone: 561-622-6610
  • Fax: 561-622-6091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0071424
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: