Provider Demographics
NPI:1669489183
Name:GANDARA, ROBERTO JUAN (MD)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:JUAN
Last Name:GANDARA
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:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-1357
Mailing Address - Country:US
Mailing Address - Phone:787-745-3508
Mailing Address - Fax:
Practice Address - Street 1:2 CALLE MUNOZ RIVERA
Practice Address - Street 2:ESQUINA GOYCO
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-2603
Practice Address - Country:US
Practice Address - Phone:787-286-2800
Practice Address - Fax:787-745-2425
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR329171100000X
PR11223208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR11223OtherMD LICENCE
PRDM 12086-5OtherNARCOTIC - STATE LICENCE
PRDM 12086-5OtherNARCOTIC - STATE LICENCE
PRG41624Medicare UPIN