Provider Demographics
NPI:1649359506
Name:RANDHAWA, GAGANDEEP (MD)
Entity type:Individual
Prefix:DR
First Name:GAGANDEEP
Middle Name:
Last Name:RANDHAWA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7225 CARLYLE XING
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3280
Mailing Address - Country:US
Mailing Address - Phone:248-539-9084
Mailing Address - Fax:248-539-9088
Practice Address - Street 1:5777 W MAPLE RD
Practice Address - Street 2:SUITE 180
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2267
Practice Address - Country:US
Practice Address - Phone:248-539-9084
Practice Address - Fax:248-539-9088
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079646207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4945645Medicaid
MII66283Medicare UPIN
MII66283Medicare UPIN