Basic Information
| Provider Information | |||||||||
| NPI: | 1811317506 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANDHI | ||||||||
| FirstName: | KUNAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1037 S STATE ROAD 7 STE 211 | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334146139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617983030 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1037 S STATE ROAD 7 STE 211 | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334146139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617983030 | ||||||||
| FaxNumber: | 5617988242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2014 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME133100 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | JE740Y | 01 | FL | PTAN NUMBER | OTHER |