Provider Demographics
NPI:1619182854
Name:GANDOLFI, MICHEAL (DR)
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
Last Name:GANDOLFI
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-4338
Mailing Address - Country:US
Mailing Address - Phone:217-345-4065
Mailing Address - Fax:
Practice Address - Street 1:2115 18TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-4338
Practice Address - Country:US
Practice Address - Phone:217-345-4065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor