Provider Demographics
NPI:1780661405
Name:GAYNOR, SANFORD H (MD)
Entity type:Individual
Prefix:DR
First Name:SANFORD
Middle Name:H
Last Name:GAYNOR
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 1:1045 W REDONDO BEACH BLVD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4128
Mailing Address - Country:US
Mailing Address - Phone:310-527-7355
Mailing Address - Fax:310-527-2528
Practice Address - Street 1:1045 W REDONDO BEACH BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4128
Practice Address - Country:US
Practice Address - Phone:310-527-7355
Practice Address - Fax:310-527-2528
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG6215207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G62150Medicaid
CAA57461Medicare UPIN
CA00G62150Medicaid