Provider Demographics
NPI:1831631035
Name:GANDEZA, EXPEDITO
Entity type:Individual
Prefix:
First Name:EXPEDITO
Middle Name:
Last Name:GANDEZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2399 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1335
Mailing Address - Country:US
Mailing Address - Phone:808-285-3113
Mailing Address - Fax:
Practice Address - Street 1:2399 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1335
Practice Address - Country:US
Practice Address - Phone:808-285-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-06
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor