Healthcare Provider Details

I. General information

NPI: 1871699249
Provider Name (Legal Business Name): SRIDHAR GOWDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 09/06/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

3818 SHOAL CREEK CT
MARTINEZ GA
30907-9431
US

V. Phone/Fax

Practice location:
  • Phone: 706-792-7688
  • Fax:
Mailing address:
  • Phone: 706-868-7796
  • Fax: 706-731-7293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number035885
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: