Provider Demographics
NPI:1386617421
Name:GANDOTRA, GAURAV (MD)
Entity type:Individual
Prefix:DR
First Name:GAURAV
Middle Name:
Last Name:GANDOTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2847
Mailing Address - Country:US
Mailing Address - Phone:714-633-4300
Mailing Address - Fax:714-463-3633
Practice Address - Street 1:1010 W CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2847
Practice Address - Country:US
Practice Address - Phone:714-633-4300
Practice Address - Fax:714-463-3633
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1587942084P0800X
PAMD425314174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101313657Medicaid
PA093488F3FMedicare ID - Type Unspecified
PA101313657Medicaid