1801311956 NPI number — SHASHIKALA BASAV GOWDA MD

Table of content: SHASHIKALA BASAV GOWDA MD (NPI 1801311956)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801311956 NPI number — SHASHIKALA BASAV GOWDA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOWDA
Provider First Name:
SHASHIKALA
Provider Middle Name:
BASAV
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOWDA
Provider Other First Name:
SHASHIKALA
Provider Other Middle Name:
BASAV
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1801311956
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11100 EUCLID AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44106-1716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-844-1171
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22201 MOROSS RD STE 252
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48236-2175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-343-3809
Provider Business Practice Location Address Fax Number:
313-417-0560
Provider Enumeration Date:
08/10/2017

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: 390200000X , with the licence number:  57030228 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0205X , with the licence number: 4301506494 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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