Provider Demographics
NPI:1962194787
Name:GANDY, MARJORIE JOANNE
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:JOANNE
Last Name:GANDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:LAVON
Mailing Address - State:TX
Mailing Address - Zip Code:75166-1626
Mailing Address - Country:US
Mailing Address - Phone:469-766-0531
Mailing Address - Fax:972-908-2633
Practice Address - Street 1:2662 W LUCAS RD
Practice Address - Street 2:
Practice Address - City:LUCAS
Practice Address - State:TX
Practice Address - Zip Code:75002-7513
Practice Address - Country:US
Practice Address - Phone:469-675-8559
Practice Address - Fax:972-908-2633
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX173863156FC0800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens