Healthcare Provider Details

I. General information

NPI: 1083864177
Provider Name (Legal Business Name): VISHAL GANDOTRA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 W CHARLESTON BLVD STE 201
LAS VEGAS NV
89146-0903
US

IV. Provider business mailing address

1930 VILLAGE CENTER CIR STE 3-448
LAS VEGAS NV
89134-6299
US

V. Phone/Fax

Practice location:
  • Phone: 702-750-0313
  • Fax: 702-487-3197
Mailing address:
  • Phone: 702-528-3557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number10594
License Number StateNV

VIII. Authorized Official

Name: DR. VISHAL GANDOTRA
Title or Position: PRESIDENT
Credential: MD
Phone: 702-528-3557