Healthcare Provider Details

I. General information

NPI: 1184151755
Provider Name (Legal Business Name): VINODHINI NAMRATHA GOWDA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S BRYN MAWR AVE
BRYN MAWR PA
19010-3143
US

IV. Provider business mailing address

5105 WINDY HOLLOW CT
GLEN ALLEN VA
23059-7535
US

V. Phone/Fax

Practice location:
  • Phone: 484-337-4097
  • Fax:
Mailing address:
  • Phone: 804-314-7806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT017873
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS020781
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS020781
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: