Provider Demographics
NPI:1336117498
Name:GANDOUR, MARY JANE MULVEY (MD)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:MULVEY
Last Name:GANDOUR
Suffix:
Gender:F
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-8286
Mailing Address - Fax:765-449-0445
Practice Address - Street 1:2020 UNION ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2694
Practice Address - Country:US
Practice Address - Phone:765-449-8286
Practice Address - Fax:765-449-0445
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040331A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INR99556Medicare UPIN
IN815170BMedicare ID - Type Unspecified