Provider Demographics
NPI:1548332992
Name:GANDOLFO, JOHN V (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:V
Last Name:GANDOLFO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:ONE ROOSEVELT AVENUE SUITE 204
Mailing Address - Street 2:JOHN V GANDOLFO MD
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960
Mailing Address - Country:US
Mailing Address - Phone:978-536-7778
Mailing Address - Fax:978-536-2998
Practice Address - Street 1:ONE ROOSEVELT AVENUE SUITE 204
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960
Practice Address - Country:US
Practice Address - Phone:978-536-7778
Practice Address - Fax:978-536-2998
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA48148207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ02927OtherBLUE SHIELD OF MA
MA61925OtherHAVARD PILGRIM HEALTHCARE
MA048148OtherTUFTS HEALTH PLANS
MA6180884Medicaid
MAJ02927Medicare ID - Type Unspecified
MA61925OtherHAVARD PILGRIM HEALTHCARE