Provider Demographics
NPI:1538529375
Name:MOHINDRA, GAURAV
Entity type:Individual
Prefix:
First Name:GAURAV
Middle Name:
Last Name:MOHINDRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RUDOLPH DR
Mailing Address - Street 2:APT 2T
Mailing Address - City:CARLE PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11514-1095
Mailing Address - Country:US
Mailing Address - Phone:714-860-6124
Mailing Address - Fax:
Practice Address - Street 1:1 RUDOLPH DR
Practice Address - Street 2:APT 2T
Practice Address - City:CARLE PLACE
Practice Address - State:NY
Practice Address - Zip Code:11514-1095
Practice Address - Country:US
Practice Address - Phone:714-860-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019562363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant