Basic Information
| Provider Information | |||||||||
| NPI: | 1811951635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANDHI | ||||||||
| FirstName: | JATIN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 109 | ||||||||
| Address2: | |||||||||
| City: | SHILOH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083530109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564519395 | ||||||||
| FaxNumber: | 8564518615 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 N BROADWAY | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | PENNSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080701253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566787474 | ||||||||
| FaxNumber: | 8566783018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 04/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 25MA03647300 | NJ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3079406 | 05 | NJ | MEDICAID | 0072366000 | 01 | NJ | AMERIHEALTH | OTHER |