Provider Demographics
NPI:1427629153
Name:GANDHI, ISHAN (OD)
Entity type:Individual
Prefix:
First Name:ISHAN
Middle Name:
Last Name:GANDHI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4356
Mailing Address - Country:US
Mailing Address - Phone:757-942-0452
Mailing Address - Fax:
Practice Address - Street 1:1201 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4356
Practice Address - Country:US
Practice Address - Phone:757-942-0452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-04
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618003052152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist