Provider Demographics
NPI:1043427396
Name:GANDY, MICHAEL CHAD (IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHAD
Last Name:GANDY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 BROOKSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-9539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ANTI-TERRORISM BATTALION, 2ND MARINE DIVISION
Practice Address - Street 2:UNIT 20165
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0165
Practice Address - Country:US
Practice Address - Phone:910-450-9431
Practice Address - Fax:910-450-9223
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman