1285836379 NPI number — DR. RACHELLE GRACE GANDICA M.D.

Table of content: DR. RACHELLE GRACE GANDICA M.D. (NPI 1285836379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285836379 NPI number — DR. RACHELLE GRACE GANDICA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANDICA
Provider First Name:
RACHELLE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285836379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 ST. NICHOLAS AVE. 2ND FLOOR
Provider Second Line Business Mailing Address:
NAOMI BERRIE DIABETES CENTER
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-851-5494
Provider Business Mailing Address Fax Number:
212-851-5493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 SAINT NICHOLAS AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-851-5494
Provider Business Practice Location Address Fax Number:
212-851-5493
Provider Enumeration Date:
06/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0205X , with the licence number:  241275-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A400045971 . This is a "MEDICARE ID" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03395113 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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