Provider Demographics
NPI:1164835625
Name:SAMARI ROMAN GANDULLA & ASOCIADOS
Entity Type:Organization
Organization Name:SAMARI ROMAN GANDULLA & ASOCIADOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTA
Authorized Official - Prefix:
Authorized Official - First Name:SAMARI
Authorized Official - Middle Name:ROMAN
Authorized Official - Last Name:GANDULLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-649-7212
Mailing Address - Street 1:1452 AVE ASHFORD
Mailing Address - Street 2:408 ADA LIGIA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-1581
Mailing Address - Country:US
Mailing Address - Phone:787-509-7212
Mailing Address - Fax:
Practice Address - Street 1:1452 AVE ASHFORD
Practice Address - Street 2:408 ADA LIGIA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1581
Practice Address - Country:US
Practice Address - Phone:787-509-7212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0855X
PR261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health