Healthcare Provider Details

I. General information

NPI: 1083634489
Provider Name (Legal Business Name): RAJESH RAMESH GANDHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST STE 303
FORT WORTH TX
76104
US

IV. Provider business mailing address

PO BOX 732973
DALLAS TX
75373-2973
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-1172
  • Fax: 817-702-1605
Mailing address:
  • Phone:
  • Fax: 817-702-7315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberL6902
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberL6902
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: