=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699935890
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KISHORE KUMAR GANDLA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2008
-----------------------------------------------------
Last Update Date | 12/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 E HURON RIVER DR
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-1051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-712-8676
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3165 ROGUE RIVER DR
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95973-8295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-929-9790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 4301500342
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------