Provider Demographics
NPI:1336109909
Name:GANDLE, LARRY (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:GANDLE
Suffix:
Gender:M
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 102222
Mailing Address - Street 2:ATTN: CREDENTIAL DEPT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:38010 MEDICAL CENTER AVE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33540-1383
Practice Address - Country:US
Practice Address - Phone:813-783-1676
Practice Address - Fax:813-783-1929
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME518032085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022168100Medicaid
FL920007525OtherRAILROAD MEDICARE
FL04730WMedicare PIN
D20967Medicare UPIN
FL920007525OtherRAILROAD MEDICARE