Healthcare Provider Details

I. General information

NPI: 1720441884
Provider Name (Legal Business Name): CHAUN GANDOLFO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 06/22/2025
Certification Date: 06/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

2799 W GRAND BLVD HENRY FORD HOSPITAL
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 313-916-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number5101025085
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: