Provider Demographics
NPI:1235768797
Name:GURAM, MAVINDER
Entity type:Individual
Prefix:
First Name:MAVINDER
Middle Name:
Last Name:GURAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 COUNTRY PLACE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-0911
Mailing Address - Country:US
Mailing Address - Phone:803-528-1934
Mailing Address - Fax:
Practice Address - Street 1:3600 FOREST DR STE 400
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4057
Practice Address - Country:US
Practice Address - Phone:803-779-7316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD91657207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology