1639379308 NPI number — DR. MITUL GANDHI M.D.

Table of content: DR. MITUL GANDHI M.D. (NPI 1639379308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639379308 NPI number — DR. MITUL GANDHI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANDHI
Provider First Name:
MITUL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639379308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3040 WILLIAMS DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-4618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-350-8400
Provider Business Mailing Address Fax Number:
39-408-6927

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2280 OPITZ BLVD STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22191-3362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-350-8400
Provider Business Practice Location Address Fax Number:
703-897-7938
Provider Enumeration Date:
07/20/2007

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: 207RH0003X , with the licence number:  0101257153 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1639379308 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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