Provider Demographics
NPI:1003131053
Name:GANDOLFI, BRAD MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:MICHAEL
Last Name:GANDOLFI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:30 N DEAN ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2807
Mailing Address - Country:US
Mailing Address - Phone:212-287-7211
Mailing Address - Fax:212-287-7210
Practice Address - Street 1:905 5TH AVE STE 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4156
Practice Address - Country:US
Practice Address - Phone:212-287-7211
Practice Address - Fax:212-287-7210
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA10153500208200000X
CA142117208200000X
NY292312-1208200000X
NYAB1876296 J48208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery