Provider Demographics
NPI:1003163593
Name:GONDAL, MARYAM (MD)
Entity Type:Individual
Prefix:MS
First Name:MARYAM
Middle Name:
Last Name:GONDAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 CEDAR STREET
Mailing Address - Street 2:BB 114
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510
Mailing Address - Country:US
Mailing Address - Phone:203-785-4184
Mailing Address - Fax:203-785-7068
Practice Address - Street 1:330 CEDAR STREET
Practice Address - Street 2:BB 114
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:203-785-4184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC40627207RN0300X
CT71978207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty