Provider Demographics
NPI:1770549321
Name:GANDIA, JUSTIN KIDD (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:KIDD
Last Name:GANDIA
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 1:4242 N DAMEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3063
Mailing Address - Country:US
Mailing Address - Phone:773-416-1411
Mailing Address - Fax:
Practice Address - Street 1:500 E 51ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2400
Practice Address - Country:US
Practice Address - Phone:312-572-2676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106332207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology