Healthcare Provider Details

I. General information

NPI: 1407050404
Provider Name (Legal Business Name): LUIS A GANDARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PLATINUM PT
LAKE MARY FL
32746-4871
US

IV. Provider business mailing address

701 PLATINUM PT
LAKE MARY FL
32746-4871
US

V. Phone/Fax

Practice location:
  • Phone: 407-206-4500
  • Fax: 407-643-2802
Mailing address:
  • Phone: 407-206-4500
  • Fax: 407-643-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD 440572
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number16675
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME109856
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: