Provider Demographics
NPI:1740584333
Name:JORGE L. GARDYN, M.D., F.A.C.P., P.C.
Entity Type:Organization
Organization Name:JORGE L. GARDYN, M.D., F.A.C.P., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARDYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP
Authorized Official - Phone:516-795-5544
Mailing Address - Street 1:4 DOROTHY GATE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-3521
Mailing Address - Country:US
Mailing Address - Phone:516-795-5544
Mailing Address - Fax:516-797-1826
Practice Address - Street 1:4 DOROTHY GATE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-3521
Practice Address - Country:US
Practice Address - Phone:516-795-5544
Practice Address - Fax:516-797-1826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10F614Medicare PIN