Healthcare Provider Details

I. General information

NPI: 1831171891
Provider Name (Legal Business Name): LAKHMAN L GONDALIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6252 YELLOWSTONE RD
CHEYENNE WY
82009-3432
US

IV. Provider business mailing address

6252 YELLOWSTONE RD
CHEYENNE WY
82009-3432
US

V. Phone/Fax

Practice location:
  • Phone: 307-778-2015
  • Fax: 307-778-7060
Mailing address:
  • Phone: 307-778-2015
  • Fax: 307-778-7060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number4234A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number19482
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number37760
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: