Provider Demographics
NPI:1114007903
Name:GANDIKOTA, GIRISH (MD)
Entity Type:Individual
Prefix:
First Name:GIRISH
Middle Name:
Last Name:GANDIKOTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GANDIKOTA
Other - Middle Name:
Other - Last Name:GIRISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:2ND FLOOR TAUBMAN CENTER RECP A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5326
Practice Address - Country:US
Practice Address - Phone:734-936-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010847342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4702324Medicaid
MII27156Medicare UPIN
MI4702324Medicaid