Healthcare Provider Details

I. General information

NPI: 1578904504
Provider Name (Legal Business Name): GURDIAL DHILLON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 07/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N 15TH ST # MS 495
PHILADELPHIA PA
19102-1101
US

IV. Provider business mailing address

2559 MEDICAL DR STE D
ALAMOGORDO NM
88310-8704
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-8220
  • Fax: 215-762-1470
Mailing address:
  • Phone: 575-434-2229
  • Fax: 575-439-5705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD2017-0292
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: