Provider Demographics
NPI:1841433448
Name:GANDOTRA, ALBA KAMAL (MD)
Entity type:Individual
Prefix:
First Name:ALBA
Middle Name:KAMAL
Last Name:GANDOTRA
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 1:7350 INDUSTRIAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5318
Mailing Address - Country:US
Mailing Address - Phone:216-732-9480
Mailing Address - Fax:
Practice Address - Street 1:7350 INDUSTRIAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5318
Practice Address - Country:US
Practice Address - Phone:216-732-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252699207Q00000X
OH35.127084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH386300Medicare PIN