Basic Information
| Provider Information | |||||||||
| NPI: | 1669489183 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANDARA | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | JUAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1357 | ||||||||
| Address2: | |||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007261357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877453508 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2 CALLE MUNOZ RIVERA | ||||||||
| Address2: | ESQUINA GOYCO | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007252603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872862800 | ||||||||
| FaxNumber: | 7877452425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 01/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | 329 | PR | N | Other Service Providers | Acupuncturist | 208D00000X | 11223 | PR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | BG5165471 | 01 | PR | DEA | OTHER | 11223 | 01 | PR | MD LICENCE | OTHER | DM 12086-5 | 01 | PR | NARCOTIC - STATE LICENCE | OTHER |