Healthcare Provider Details

I. General information

NPI: 1306069562
Provider Name (Legal Business Name): GAURAV TANDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6885 BELFORT OAKS PL STE 230
JACKSONVILLE FL
32216-6283
US

IV. Provider business mailing address

12620 BEACH BLVD STE 3-422
JACKSONVILLE FL
32246-7131
US

V. Phone/Fax

Practice location:
  • Phone: 904-593-5333
  • Fax: 904-593-5334
Mailing address:
  • Phone: 623-734-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-097593
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number125049759
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01066629
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME121997
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: