MEDICARE: DR. JUSTIN KIDD GANDIA 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	207V00000X	Obstetrics & Gynecology Physician	036-106332	IL

General Provider Information

NPI Number	:	1770549321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUSTIN KIDD GANDIA M.D.

Provider Business Mailing Address
First Line	:	4242 N DAMEN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3063
Country	:	US
Telephone Number	:	773-416-1411
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 E 51ST ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-2400
Country	:	US
Telephone Number	:	312-572-2676
Fax Number	:

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

Provider Enumeration Date	:	04/24/2006
Last Update Date	:	04/23/2021

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