Provider Demographics
NPI: | 1780661405 |
---|---|
Name: | GAYNOR, SANFORD H (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | SANFORD |
Middle Name: | H |
Last Name: | GAYNOR |
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: | 1045 W REDONDO BEACH BLVD |
Mailing Address - Street 2: | SUITE 115 |
Mailing Address - City: | GARDENA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90247-4128 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-527-7355 |
Mailing Address - Fax: | 310-527-2528 |
Practice Address - Street 1: | 1045 W REDONDO BEACH BLVD |
Practice Address - Street 2: | SUITE 115 |
Practice Address - City: | GARDENA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90247-4128 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-527-7355 |
Practice Address - Fax: | 310-527-2528 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-12-22 |
Last Update Date: | 2007-10-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G6215 | 207R00000X, 207RN0300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 00G62150 | Medicaid | |
CA | A57461 | Medicare UPIN | |
CA | 00G62150 | Medicaid |