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NPI Code Detail

MEDICARE: DR. JONATHAN LEROY GANDY O.D.

MEDICARE: DR. JONATHAN LEROY GANDY O.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
1152W00000XOptometrist8155TTX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
18155OTHERTXOPTOMETRY LICENSE

General Provider Information

NPI Number : 1790126373
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JONATHAN LEROY GANDY O.D.
Provider Business Mailing Address
First Line : 3345 PLAZA 10 DR STE B
Second Line :
City : BEAUMONT
State : TX
Zip : 77707-2553
Country : US
Telephone Number : 409-833-0009
Fax Number : 409-833-9039
Provider Business Practice Location Address
First Line : 3345 PLAZA 10 DR STE B
Second Line :
City : BEAUMONT
State : TX
Zip : 77707-2553
Country : US
Telephone Number : 409-833-0444
Fax Number : 409-833-9039
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/11/2013
Last Update Date : 11/09/2021

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