Individual
ROGER B GANDIONCO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1500 DARLINGTON AVE, SUITE 300, CRAWFORDSVILLE, IN 47933-2060
(765) 362-4940
(765) 362-1302
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01069499A
IN
207Q00000X
Family Medicine Physician
BP10030957
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201026170
—
IN
01
—
M400075748
MEDICARE PROVIDER PTAN
IN
Enumeration date
07/01/2008
Last updated
12/16/2021
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