Provider Demographics
NPI:1790126373
Name:GANDY, JONATHAN LEROY (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LEROY
Last Name:GANDY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 PLAZA 10 DR STE B
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-2553
Mailing Address - Country:US
Mailing Address - Phone:409-833-0009
Mailing Address - Fax:409-833-9039
Practice Address - Street 1:3345 PLAZA 10 DR STE B
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2553
Practice Address - Country:US
Practice Address - Phone:409-833-0444
Practice Address - Fax:409-833-9039
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8155T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8155OtherOPTOMETRY LICENSE