Healthcare Provider Details

I. General information

NPI: 1043821846
Provider Name (Legal Business Name): RIDDHI GANDHI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 2ND ST
BLOOMINGTON IN
47403-2317
US

IV. Provider business mailing address

601 W 2ND ST
BLOOMINGTON IN
47403-2317
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-9515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003035A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: