Healthcare Provider Details

I. General information

NPI: 1891375671
Provider Name (Legal Business Name): TIMOTHY ROBERT GANDOLFO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 MIDDLEVILLE RD
NORTHPORT NY
11768-2200
US

IV. Provider business mailing address

79 MIDDLEVILLE RD
NORTHPORT NY
11768-2200
US

V. Phone/Fax

Practice location:
  • Phone: 631-261-4400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number330997
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number330997
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: