MEDICARE: SAMARI ROMAN- GANDULLA PSYCHOLOGIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	3040	PR
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center	3040	PR

General Provider Information

NPI Number	:	1871762526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMARI ROMAN- GANDULLA PSYCHOLOGIST

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

Provider Business Practice Location Address
First Line	:	1452 ASHFORD
Second Line	:	COND. ADALIGIA, SUITE 308
City	:	SAN JUAN
State	:	PR
Zip	:	00907-1581
Country	:	US
Telephone Number	:	787-649-7212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2008
Last Update Date	:	09/08/2011

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