1053611566 NPI number — AMITHA GONA M.D

Table of content: AMITHA GONA M.D (NPI 1053611566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053611566 NPI number — AMITHA GONA M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONA
Provider First Name:
AMITHA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GONA
Provider Other First Name:
AMITHA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.,
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053611566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
875 OAK ST SE STE 4030
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97301-3984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-561-6444
Provider Business Mailing Address Fax Number:
503-561-6440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3025 RYAN DR SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-5057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-485-0350
Provider Business Practice Location Address Fax Number:
503-561-6442
Provider Enumeration Date:
10/30/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  MD , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500687580 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".