Provider Demographics
NPI:1306892369
Name:GORDHAN, AJEET D (MD)
Entity type:Individual
Prefix:DR
First Name:AJEET
Middle Name:D
Last Name:GORDHAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2200 FORT JESSE RD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6286
Mailing Address - Country:US
Mailing Address - Phone:309-452-1788
Mailing Address - Fax:309-862-1302
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:SUITE 280
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-452-1788
Practice Address - Fax:309-862-1302
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2016-11-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL361102222085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110222*1Medicaid
IL036110222*1Medicaid
ILH62332Medicare UPIN