Provider Demographics
NPI:1265779334
Name:COLORECTAL CENTER OF SAN DIEGO, INC.
Entity type:Organization
Organization Name:COLORECTAL CENTER OF SAN DIEGO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DHRUVIL
Authorized Official - Middle Name:PRADIP
Authorized Official - Last Name:GANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-691-9733
Mailing Address - Street 1:2095 W VISTA WAY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:760-477-6056
Practice Address - Street 1:2095 W VISTA WAY
Practice Address - Street 2:SUITE 106
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6027
Practice Address - Country:US
Practice Address - Phone:760-691-9733
Practice Address - Fax:760-477-6056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103200208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty