Provider Demographics
NPI:1053550079
Name:GANDOLFO, FREDERICK JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOSEPH
Last Name:GANDOLFO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2680
Mailing Address - Country:US
Mailing Address - Phone:631-350-6077
Mailing Address - Fax:631-271-2272
Practice Address - Street 1:205 E MAIN ST STE 1-4
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-7931
Practice Address - Country:US
Practice Address - Phone:631-350-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-14
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY253535207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology