Basic Information
Provider Information
NPI: 1376529461
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GANDOLA
FirstName: CARL
MiddleName: D
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 635283
Address2:  
City: CINCINNATI
State: OH
PostalCode: 452635283
CountryCode: US
TelephoneNumber: 8596558980
FaxNumber: 8596558981
Practice Location
Address1: 1500 JAMES SIMPSON JR WAY
Address2: SUITE 201
City: COVINGTON
State: KY
PostalCode: 410110801
CountryCode: US
TelephoneNumber: 8596558980
FaxNumber: 8596558981
Other Information
ProviderEnumerationDate: 12/20/2005
LastUpdateDate: 09/12/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X45251KYY Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000X35043698OHN Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000XTP405KYN Allopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
40157805OH MEDICAID
6478530605KY MEDICAID


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