Healthcare Provider Details

I. General information

NPI: 1063613909
Provider Name (Legal Business Name): PRADEEP GIDWANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3160 CAMINO DEL RIO S SUITE115
SAN DIEGO CA
92108-3813
US

IV. Provider business mailing address

4818 BARBAROSSA DR
SAN DIEGO CA
92115-3732
US

V. Phone/Fax

Practice location:
  • Phone: 619-281-2291
  • Fax:
Mailing address:
  • Phone: 619-886-6562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA76477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: