Provider Demographics
NPI:1811491582
Name:GANDERT, KATHERINE LOUISE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LOUISE
Last Name:GANDERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:LOUISE
Other - Last Name:GANDERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4740 S I 10 SERVICE RD W STE 120
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-1214
Mailing Address - Country:US
Mailing Address - Phone:504-988-5458
Mailing Address - Fax:504-988-6808
Practice Address - Street 1:4740 S I 10 SERVICE RD W STE 120
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1214
Practice Address - Country:US
Practice Address - Phone:504-988-5458
Practice Address - Fax:504-988-6808
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301507024208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program