Basic Information
| Provider Information | |||||||||
| NPI: | 1558494690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOWDA | ||||||||
| FirstName: | VINAY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1457 | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247011457 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 N DECATUR RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300335918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045015256 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 59160 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | P00605278 | 01 | RAILROAD MEDICARE - EASTSIDE | OTHER | P00698646 | 01 | RAILROAD MEDICARE-DEKALB | OTHER | 775076527A- EASTSIDE | 05 | GA | MEDICAID | 775076527B - DEKALB | 05 | GA | MEDICAID |