Provider Demographics
NPI:1477883965
Name:KANDANKULAM, GINCY LIZ (MD)
Entity Type:Individual
Prefix:
First Name:GINCY
Middle Name:LIZ
Last Name:KANDANKULAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 S JOG RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-2981
Mailing Address - Country:US
Mailing Address - Phone:561-784-4930
Mailing Address - Fax:561-784-4931
Practice Address - Street 1:2465 S STATE ROAD 7 STE 800
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-9348
Practice Address - Country:US
Practice Address - Phone:561-784-4930
Practice Address - Fax:561-793-4544
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL121147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine