1548332992 NPI number — JOHN V GANDOLFO MD

Table of content: JOHN V GANDOLFO MD (NPI 1548332992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548332992 NPI number — JOHN V GANDOLFO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANDOLFO
Provider First Name:
JOHN
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1548332992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ONE ROOSEVELT AVENUE SUITE 204
Provider Second Line Business Mailing Address:
JOHN V GANDOLFO MD
Provider Business Mailing Address City Name:
PEABODY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-536-7778
Provider Business Mailing Address Fax Number:
978-536-2998

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE ROOSEVELT AVENUE SUITE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEABODY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-536-7778
Provider Business Practice Location Address Fax Number:
978-536-2998
Provider Enumeration Date:
11/14/2006

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: 207R00000X , with the licence number:  48148 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RG0100X , with the licence number: 48148 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: J02927 . This is a "BLUE SHIELD OF MA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 61925 . This is a "HAVARD PILGRIM HEALTHCARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 048148 . This is a "TUFTS HEALTH PLANS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 6180884 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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