Healthcare Provider Details

I. General information

NPI: 1649072307
Provider Name (Legal Business Name): GYAN CHETAN MOORTHY MBE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF GENERAL PEDIATRICS
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

104 CAMINO PENASCO
EL PASO TX
79912-3438
US

V. Phone/Fax

Practice location:
  • Phone: 915-222-1513
  • Fax:
Mailing address:
  • Phone: 915-222-1513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMT234481
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: