Provider Demographics
NPI:1437117322
Name:NAHL, GURSHARAN S (MD)
Entity Type:Individual
Prefix:
First Name:GURSHARAN
Middle Name:S
Last Name:NAHL
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:PO BOX 241011
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-9511
Mailing Address - Country:US
Mailing Address - Phone:209-339-7435
Mailing Address - Fax:209-339-7858
Practice Address - Street 1:10200 TRINITY PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7286
Practice Address - Country:US
Practice Address - Phone:209-948-0808
Practice Address - Fax:209-948-0807
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42515207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C425150Medicaid
CAD14026Medicare UPIN
CA00C425153Medicare ID - Type UnspecifiedMEDICARE NUMBER