Provider Demographics
NPI:1528050978
Name:GANDHI, MRUGENDRA M (MD)
Entity type:Individual
Prefix:DR
First Name:MRUGENDRA
Middle Name:M
Last Name:GANDHI
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 1:108 LEGION DR
Mailing Address - Street 2:STE A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4898
Mailing Address - Country:US
Mailing Address - Phone:847-816-4957
Mailing Address - Fax:847-816-1517
Practice Address - Street 1:208 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1604
Practice Address - Country:US
Practice Address - Phone:224-715-5571
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-20
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36 51634208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery