Provider Demographics
NPI:1558676197
Name:KANDASAMY, GAYATHRI
Entity Type:Individual
Prefix:DR
First Name:GAYATHRI
Middle Name:
Last Name:KANDASAMY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 GOODYEAR AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-1195
Mailing Address - Country:US
Mailing Address - Phone:256-494-4768
Mailing Address - Fax:256-494-4793
Practice Address - Street 1:1007 GOODYEAR AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1195
Practice Address - Country:US
Practice Address - Phone:256-494-4768
Practice Address - Fax:256-494-4793
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.32644207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL153315Medicaid
AL102I113931Medicare PIN