Provider Demographics
NPI:1386681526
Name:GANDENBERGER, KURT L (MD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:L
Last Name:GANDENBERGER
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 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2619
Mailing Address - Country:US
Mailing Address - Phone:803-782-4278
Mailing Address - Fax:803-782-3445
Practice Address - Street 1:6704 WHITE HORSE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-2504
Practice Address - Country:US
Practice Address - Phone:864-294-1392
Practice Address - Fax:864-294-0424
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14391207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC14391Medicaid
SC14391Medicaid