Healthcare Provider Details

I. General information

NPI: 1720386477
Provider Name (Legal Business Name): KRISHNA GIDWANI COF, CDME
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2011
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 GRAPE ST STE 2A
NEW BEDFORD MA
02740-2104
US

IV. Provider business mailing address

92 GRAPE ST STE 2A
NEW BEDFORD MA
02740-2104
US

V. Phone/Fax

Practice location:
  • Phone: 321-402-6716
  • Fax: 508-819-4989
Mailing address:
  • Phone: 321-402-6716
  • Fax: 508-819-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License NumberC52107
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberCPED3498
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: