Provider Demographics
NPI:1639379308
Name:GANDHI, MITUL (MD)
Entity Type:Individual
Prefix:DR
First Name:MITUL
Middle Name:
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 1:3040 WILLIAMS DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4618
Mailing Address - Country:US
Mailing Address - Phone:571-350-8400
Mailing Address - Fax:039-408-6927
Practice Address - Street 1:2280 OPITZ BLVD STE 130
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3362
Practice Address - Country:US
Practice Address - Phone:715-350-8400
Practice Address - Fax:703-897-7938
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101257153207RH0003X, 207RH0003X
MI4301090094390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1639379308Medicaid
VA1639379308Medicaid