Healthcare Provider Details

I. General information

NPI: 1588004493
Provider Name (Legal Business Name): VIPAL DINESH GANDHI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 7TH ST STE 2
SANTA MONICA CA
90401-1614
US

IV. Provider business mailing address

1234 7TH ST STE 2
SANTA MONICA CA
90401-1614
US

V. Phone/Fax

Practice location:
  • Phone: 310-395-5778
  • Fax: 310-458-9754
Mailing address:
  • Phone: 310-395-5778
  • Fax: 310-458-9754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: