Healthcare Provider Details

I. General information

NPI: 1700942877
Provider Name (Legal Business Name): CHANDRAKALA B GOWDA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5475 S 500 E
OGDEN UT
84405-6905
US

IV. Provider business mailing address

5475 S 500 E
OGDEN UT
84405-6905
US

V. Phone/Fax

Practice location:
  • Phone: 801-476-4280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number3777991205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: