Provider Demographics
NPI:1083663694
Name:GANDOTRA, SUSHEER (MD)
Entity Type:Individual
Prefix:
First Name:SUSHEER
Middle Name:
Last Name:GANDOTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E. BROWN ST.
Mailing Address - Street 2:POCONO HEALTHCARE MGMT.-PROFESSIONAL CENTER
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301
Mailing Address - Country:US
Mailing Address - Phone:570-420-4951
Mailing Address - Fax:570-476-3754
Practice Address - Street 1:175 E BROWN ST
Practice Address - Street 2:SUITE 114
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3098
Practice Address - Country:US
Practice Address - Phone:570-426-2301
Practice Address - Fax:570-426-2306
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0008498207RI0200X
PAMD435097207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1083663694OtherNPI
PA1021961250001Medicaid
PA843314LJYMedicare PIN