Provider Demographics
NPI:1396093068
Name:GUJRAL, INDER S (MD)
Entity type:Individual
Prefix:
First Name:INDER
Middle Name:S
Last Name:GUJRAL
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 1:8795 ENDLESS OCEAN WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5938
Mailing Address - Country:US
Mailing Address - Phone:410-290-1112
Mailing Address - Fax:
Practice Address - Street 1:8795 ENDLESS OCEAN WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5938
Practice Address - Country:US
Practice Address - Phone:410-290-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.045890208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0452620Medicaid
GUO492941Medicare UPIN