Provider Demographics
NPI:1043710981
Name:GHANTIWALA, VIDUR PRAVIN (DO)
Entity Type:Individual
Prefix:
First Name:VIDUR
Middle Name:PRAVIN
Last Name:GHANTIWALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4513 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-9033
Mailing Address - Country:US
Mailing Address - Phone:239-591-2803
Mailing Address - Fax:
Practice Address - Street 1:4513 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-9033
Practice Address - Country:US
Practice Address - Phone:239-591-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS181792081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine