Healthcare Provider Details

I. General information

NPI: 1558701748
Provider Name (Legal Business Name): DR. GAURANG NANDKISHOR VAIDYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2013
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-5173
US

IV. Provider business mailing address

3306 SHASTA DR
SAN MATEO CA
94403-3709
US

V. Phone/Fax

Practice location:
  • Phone: 310-923-2034
  • Fax:
Mailing address:
  • Phone: 310-923-2034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number49637
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number103698
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License NumberA162316
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number103698
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number49637
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: