Provider Demographics
NPI:1679641039
Name:MALHOTRA, GAURAV VIJAI (MD)
Entity Type:Individual
Prefix:DR
First Name:GAURAV
Middle Name:VIJAI
Last Name:MALHOTRA
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 1:3378 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-2460
Mailing Address - Country:US
Mailing Address - Phone:352-796-7171
Mailing Address - Fax:352-678-5300
Practice Address - Street 1:3378 MARINER BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-2460
Practice Address - Country:US
Practice Address - Phone:352-796-7171
Practice Address - Fax:352-556-4889
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256108500Medicaid
FL44484OtherBCBS
FL44484WMedicare UPIN