Healthcare Provider Details

I. General information

NPI: 1336137603
Provider Name (Legal Business Name): VISHAL GANDOTRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 06/28/2020
Certification Date: 06/28/2020
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: 702-945-2436
  • Fax: 702-487-3197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number10594
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10594
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: