MEDICARE: DR. PRADEEP GIDWANI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A76477	CA

General Provider Information

NPI Number	:	1063613909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRADEEP GIDWANI MD

Provider Business Mailing Address
First Line	:	4818 BARBAROSSA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-3732
Country	:	US
Telephone Number	:	619-886-6562
Fax Number	:

Provider Business Practice Location Address
First Line	:	3160 CAMINO DEL RIO S
Second Line	:	SUITE115
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3813
Country	:	US
Telephone Number	:	619-281-2291
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	07/08/2007

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