MEDICARE: DR. JORGE L. GARDYN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	164119	NY

General Provider Information

NPI Number	:	1629060983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORGE L. GARDYN M.D.

Provider Business Mailing Address
First Line	:	618 BROADWAY
Second Line	:
City	:	AMITYVILLE
State	:	NY
Zip	:	11701-2124
Country	:	US
Telephone Number	:	516-795-5544
Fax Number	:	516-797-1826

Provider Business Practice Location Address
First Line	:	618 BROADWAY
Second Line	:
City	:	AMITYVILLE
State	:	NY
Zip	:	11701-2124
Country	:	US
Telephone Number	:	516-795-5544
Fax Number	:	516-797-1826

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	04/28/2011

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