Healthcare Provider Details

I. General information

NPI: 1811334485
Provider Name (Legal Business Name): JAYASHREE T. GOWDA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 35TH AVE
MOLINE IL
61265-6176
US

IV. Provider business mailing address

612 35TH AVE
MOLINE IL
61265-6176
US

V. Phone/Fax

Practice location:
  • Phone: 309-788-0014
  • Fax: 309-623-4638
Mailing address:
  • Phone: 309-788-0014
  • Fax: 309-623-4638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number036148094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: