Provider Demographics
NPI:1194848317
Name:GANDHI, KEVIN K (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:GANDHI
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 1:1530 S UNION AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1954
Mailing Address - Country:US
Mailing Address - Phone:253-272-8285
Mailing Address - Fax:253-759-3213
Practice Address - Street 1:1530 S UNION AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1954
Practice Address - Country:US
Practice Address - Phone:253-272-8285
Practice Address - Fax:253-759-3213
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000317472088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1088632Medicaid
WAF79371Medicare UPIN
WA115000910Medicare ID - Type Unspecified