Provider Demographics
NPI:1831171891
Name:GONDALIA, LAKHMAN L (MD)
Entity type:Individual
Prefix:
First Name:LAKHMAN
Middle Name:L
Last Name:GONDALIA
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 1:6252 YELLOWSTONE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3432
Mailing Address - Country:US
Mailing Address - Phone:307-778-2015
Mailing Address - Fax:307-778-7060
Practice Address - Street 1:6252 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3432
Practice Address - Country:US
Practice Address - Phone:307-778-2015
Practice Address - Fax:307-778-7060
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4234A207RA0201X
NE19482207RA0201X
CO37760207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
030005402OtherMEDICARE RR
NE10024964200Medicaid
WY118095901Medicaid
D93762Medicare UPIN
NE10024964200Medicaid
WY9525Medicare ID - Type Unspecified