Healthcare Provider Details

I. General information

NPI: 1588784334
Provider Name (Legal Business Name): PRAVIN T GOUD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 COUNTRY CLUB PKWY STE A
EUGENE OR
97401-6025
US

IV. Provider business mailing address

PO BOX 70368
SPRINGFIELD OR
97475-0120
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-1559
  • Fax: 541-683-1709
Mailing address:
  • Phone: 541-485-2777
  • Fax: 541-246-2353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301080583
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberMD209034
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500806693
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: