Provider Demographics
NPI:1568417442
Name:GANDY, PAUL E (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:GANDY
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 1:830 NORTH BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2542
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:830 N THEATRE DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1700
Practice Address - Country:US
Practice Address - Phone:765-662-4142
Practice Address - Fax:419-866-5453
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059985A2085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200509010Medicaid
IN000000519329OtherANTHEM
INP00414325OtherMEDICARE RAILROAD
IN000000519329OtherANTHEM
INB04758Medicare UPIN
INP00414325OtherMEDICARE RAILROAD