Provider Demographics
NPI:1518963008
Name:GANDARA, JOSE R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
Last Name:GANDARA
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 6403
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-6403
Mailing Address - Country:US
Mailing Address - Phone:787-832-9333
Mailing Address - Fax:
Practice Address - Street 1:19 CALLE POST N
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-6634
Practice Address - Country:US
Practice Address - Phone:787-832-9333
Practice Address - Fax:787-832-9333
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3011207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE00116Medicare UPIN