Basic Information
Provider Information | |||||||||
NPI: | 1083663694 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GANDOTRA | ||||||||
FirstName: | SUSHEER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 206 E. BROWN ST. | ||||||||
Address2: | POCONO HEALTHCARE MGMT.-PROFESSIONAL CENTER | ||||||||
City: | EAST STROUDSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 18301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5704204951 | ||||||||
FaxNumber: | 5704763754 | ||||||||
Practice Location | |||||||||
Address1: | 175 E BROWN ST | ||||||||
Address2: | SUITE 114 | ||||||||
City: | EAST STROUDSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 183013098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5704262301 | ||||||||
FaxNumber: | 5704262306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2006 | ||||||||
LastUpdateDate: | 12/29/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | C1-0008498 | DE | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | MD435097 | PA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | 1083663694 | 01 | DE | NPI | OTHER | 1021961250001 | 05 | PA |   | MEDICAID |