Provider Demographics
NPI:1033117437
Name:GANDELMAN, GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:GANDELMAN
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 1:81 HOLLY HILL LN FL 3
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6071
Mailing Address - Country:US
Mailing Address - Phone:203-869-5515
Mailing Address - Fax:203-869-5765
Practice Address - Street 1:81 HOLLY HILL LN FL 3
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6071
Practice Address - Country:US
Practice Address - Phone:203-869-5515
Practice Address - Fax:203-869-5765
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-09
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218641174400000X, 207RC0000X
CT44021207R00000X, 207RC0000X
FLME136084207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02646115Medicaid
NYH51186Medicare UPIN
NY02646115Medicaid