Healthcare Provider Details

I. General information

NPI: 1265620728
Provider Name (Legal Business Name): GURDAVER SINGH DHALIWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SHAW AVE STE 101
CLOVIS CA
93611-4096
US

IV. Provider business mailing address

1555 SHAW AVE STE 101
CLOVIS CA
93611-4096
US

V. Phone/Fax

Practice location:
  • Phone: 559-246-3670
  • Fax:
Mailing address:
  • Phone: 559-324-7001
  • Fax: 559-324-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA101525
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: