Basic Information
| Provider Information | |||||||||
| NPI: | 1376529461 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANDOLA | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TP405 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35043698 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 45251 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64785306 | 05 | KY | MEDICAID | 401578 | 05 | OH | MEDICAID |