Provider Demographics
NPI:1629060983
Name:GARDYN, JORGE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:GARDYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JORGE
Other - Middle Name:L
Other - Last Name:GARDYN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, FACP, PC
Mailing Address - Street 1:618 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2124
Mailing Address - Country:US
Mailing Address - Phone:516-795-5544
Mailing Address - Fax:516-797-1826
Practice Address - Street 1:618 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2124
Practice Address - Country:US
Practice Address - Phone:516-795-5544
Practice Address - Fax:516-797-1826
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164119174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10F641Medicare ID - Type Unspecified
NYD91935Medicare UPIN