Provider Demographics
NPI:1306069562
Name:TANDON, GAURAV (MD)
Entity type:Individual
Prefix:DR
First Name:GAURAV
Middle Name:
Last Name:TANDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12620 BEACH BLVD STE 3-422
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-7131
Mailing Address - Country:US
Mailing Address - Phone:623-734-5400
Mailing Address - Fax:
Practice Address - Street 1:6885 BELFORT OAKS PL STE 230
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6283
Practice Address - Country:US
Practice Address - Phone:904-593-5333
Practice Address - Fax:904-593-5334
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-097593207R00000X
IL125049759207RA0000X
IN01066629208M00000X
FLME121997207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ35919301Medicaid
IN000000622778OtherANTHEM
IN200943860Medicaid
IN200943860Medicaid
AZ35919301Medicaid