Healthcare Provider Details

I. General information

NPI: 1033165618
Provider Name (Legal Business Name): JOSE E DE LA GANDARA MD ANGELA PEDRAZA MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2161 PALM BEACH LAKES BLVD SUITE 215
WEST PALM BEACH FL
33409-6607
US

IV. Provider business mailing address

2161 PALM BEACH LAKES BLVD SUITE 215
WEST PALM BEACH FL
33409-6607
US

V. Phone/Fax

Practice location:
  • Phone: 561-687-2111
  • Fax: 561-687-1777
Mailing address:
  • Phone: 561-687-2111
  • Fax: 561-687-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSE E DE LA GANDARA
Title or Position: CO OWNER
Credential: MD
Phone: 561-687-2111