1871762526 NPI number — SAMARI ROMAN- GANDULLA PSYCHOLOGIST

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871762526 NPI number — SAMARI ROMAN- GANDULLA PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROMAN- GANDULLA
Provider First Name:
SAMARI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYCHOLOGIST
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:
1871762526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 932
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DORADO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00646-0932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-649-7212
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1452 ASHFORD
Provider Second Line Business Practice Location Address:
COND. ADALIGIA, SUITE 308
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00907-1581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-649-7212
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2008

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: 103T00000X , with the licence number:  3040 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X , with the licence number: 3040 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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