Healthcare Provider Details

I. General information

NPI: 1043306921
Provider Name (Legal Business Name): JYOTI R GANDHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 25 ELMHURST AVE
ELMHURST NY
11373-3359
US

IV. Provider business mailing address

84 25 ELMHURST AVE
ELMHURST NY
11373-3359
US

V. Phone/Fax

Practice location:
  • Phone: 718-457-0500
  • Fax: 718-457-0501
Mailing address:
  • Phone: 718-457-0500
  • Fax: 718-457-0501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number110797
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00198210
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: