Provider Demographics
NPI:1013960186
Name:GHANDIVEL, KEERAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEERAN
Middle Name:
Last Name:GHANDIVEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ILANKEERAN
Other - Middle Name:
Other - Last Name:GHANDIVEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-235-5390
Mailing Address - Fax:319-233-1630
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3886
Practice Address - Fax:319-233-1630
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-35099207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA421417307G7OtherJOHN DEERE HEALTH CARE
H89555Medicare UPIN
IA0414649Medicaid
IAI9886Medicare ID - Type Unspecified
IA34657OtherWELLMARK INS PLAN