Provider Demographics
NPI:1720053168
Name:GANDLMAYR, JACK M (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:GANDLMAYR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:12255 DE PAUL DR
Mailing Address - Street 2:SUITE 445
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:314-344-6817
Mailing Address - Fax:314-344-7979
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:SUITE 445
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-344-6817
Practice Address - Fax:314-344-7979
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO26824207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A23180Medicare UPIN