Provider Demographics
NPI:1720386477
Name:GIDWANI, KRISHNA (COF, CDME)
Entity Type:Individual
Prefix:MR
First Name:KRISHNA
Middle Name:
Last Name:GIDWANI
Suffix:
Gender:M
Credentials:COF, CDME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 GRAPE ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-2104
Mailing Address - Country:US
Mailing Address - Phone:321-402-6716
Mailing Address - Fax:508-819-4989
Practice Address - Street 1:92 GRAPE ST STE 2A
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-2104
Practice Address - Country:US
Practice Address - Phone:321-402-6716
Practice Address - Fax:508-819-4989
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-04
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC52107225000000X
DECPED3498174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty