Provider Demographics
NPI:1851398218
Name:FIDAI, GULZAR (MD)
Entity type:Individual
Prefix:DR
First Name:GULZAR
Middle Name:
Last Name:FIDAI
Suffix:
Gender:F
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3565 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1637
Practice Address - Country:US
Practice Address - Phone:310-214-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC156740207R00000X
IL036085843207R00000X, 208M00000X
WI531208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085843Medicaid
ILF57773Medicare UPIN
ILL99395Medicare ID - Type Unspecified