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General NPI Number Information
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NPI Number | 1528139748
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Entity Type | Organization
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Legal Business Name | MAIN STREET FAMILY PRACTICE
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Dates
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Enumeration Date | 11/10/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1336 E MAIN ST
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City | COLUMBUS
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State | OH
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Zip | 43205-2081
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Country | US
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Telephone | 614-253-8537
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Fax | 614-253-8539
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Provider Business Mailing Address
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Address Line | 1336 E MAIN ST
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City | COLUMBUS
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State | OH
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Zip | 43205-2081
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Country | US
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Telephone | 614-253-8537
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Fax | 614-253-8539
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. CHANDRE C GOWDA
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Credential | M.D.
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Telephone | 614-253-8537
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 35085235
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License Number State | OH
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