Healthcare Provider Details

I. General information

NPI: 1346668555
Provider Name (Legal Business Name): PRIDVI GAUTHAM KANDAGATLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1983 SLOAN PL STE 11
SAINT PAUL MN
55117-2004
US

IV. Provider business mailing address

4200 DAHLBERG DR STE 300
GOLDEN VALLEY MN
55422-4841
US

V. Phone/Fax

Practice location:
  • Phone: 651-312-1620
  • Fax: 651-312-1570
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number71756
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: