Healthcare Provider Details

I. General information

NPI: 1265779334
Provider Name (Legal Business Name): COLORECTAL CENTER OF SAN DIEGO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 01/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 W VISTA WAY SUITE 106
VISTA CA
92083-6027
US

IV. Provider business mailing address

2095 W VISTA WAY SUITE 106
VISTA CA
92083-6027
US

V. Phone/Fax

Practice location:
  • Phone: 760-691-9733
  • Fax: 760-477-6056
Mailing address:
  • Phone:
  • Fax: 760-477-6056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA103200
License Number StateCA

VIII. Authorized Official

Name: DR. DHRUVIL PRADIP GANDHI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-691-9733