Provider Demographics
NPI:1740211101
Name:GANDOLFI, ROY J (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:J
Last Name:GANDOLFI
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 1:3725 W 4100 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:801-965-3526
Practice Address - Street 1:3725 W 4100 SOUTH
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:801-965-3526
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1689861205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C63713Medicare UPIN