Provider Demographics
NPI:1336137603
Name:GANDOTRA, VISHAL (MD)
Entity Type:Individual
Prefix:DR
First Name:VISHAL
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 1:1930 VILLAGE CENTER CIR STE 3-448
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-6299
Mailing Address - Country:US
Mailing Address - Phone:702-945-2436
Mailing Address - Fax:702-487-3197
Practice Address - Street 1:5701 W CHARLESTON BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-0903
Practice Address - Country:US
Practice Address - Phone:702-750-0313
Practice Address - Fax:702-487-3197
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2020-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10594207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVH92521Medicare UPIN
A92521Medicare UPIN