Basic Information
| Provider Information | |||||||||
| NPI: | 1437512753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONDAL | ||||||||
| FirstName: | KHUBAIB | ||||||||
| MiddleName: | NAZIR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 847 46TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112201612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474320944 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10500 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138652246 | ||||||||
| FaxNumber: | 5138655596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2016 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 301003 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 35.136515 | OH | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 2565399 | 05 | OH | MEDICAID |