Provider Demographics
NPI:1770761264
Name:GANDOLFO, EVE A (MPT)
Entity type:Individual
Prefix:MRS
First Name:EVE
Middle Name:A
Last Name:GANDOLFO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MRS
Other - First Name:EVE
Other - Middle Name:A
Other - Last Name:RAZZETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:44927 GEORGE WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4295
Mailing Address - Country:US
Mailing Address - Phone:571-291-9936
Mailing Address - Fax:571-918-4935
Practice Address - Street 1:44927 GEORGE WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4295
Practice Address - Country:US
Practice Address - Phone:571-291-9936
Practice Address - Fax:571-918-4935
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1770761264Medicaid
VA192935OtherBCBS PHYSICAL THERAPY
VA7762447OtherAETNA
VAP00608797OtherMEDICARE RAILROAD
VA192935OtherBCBS PHYSICAL THERAPY
VA017188T54Medicare PIN