Provider Demographics
NPI:1033929989
Name:GANDU, JENOM
Entity type:Individual
Prefix:MR
First Name:JENOM
Middle Name:
Last Name:GANDU
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 1:7910 S 83RD ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3930
Mailing Address - Country:US
Mailing Address - Phone:402-730-8738
Mailing Address - Fax:
Practice Address - Street 1:4920 S 65TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-1906
Practice Address - Country:US
Practice Address - Phone:402-730-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor