Provider Demographics
NPI:1730396755
Name:BISUNDIAL, GOWTAMDYAL (RPH)
Entity type:Individual
Prefix:PROF
First Name:GOWTAMDYAL
Middle Name:
Last Name:BISUNDIAL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15011 SW 169TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33187-1735
Mailing Address - Country:US
Mailing Address - Phone:305-283-0091
Mailing Address - Fax:305-235-6922
Practice Address - Street 1:15011 SW 169TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33187-1735
Practice Address - Country:US
Practice Address - Phone:305-283-0091
Practice Address - Fax:305-235-6922
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS25696183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist