Provider Demographics
NPI:1629310735
Name:GOTTFRIED BLACKMORE, ANDRES CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:CARLOS
Last Name:GOTTFRIED BLACKMORE
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 1:505 EAST 70TH STREET
Mailing Address - Street 2:WEILL CORNELL INTERNAL MEDICINE ASSOCIATES
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:212-746-9663
Mailing Address - Fax:212-746-3609
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA136219207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program