Healthcare Provider Details

I. General information

NPI: 1275573107
Provider Name (Legal Business Name): CHARLES E GAMBLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 WATERMELON RD
NORTHPORT AL
35473-5204
US

IV. Provider business mailing address

4410 WATERMELON RD
NORTHPORT AL
35473-5204
US

V. Phone/Fax

Practice location:
  • Phone: 205-345-1520
  • Fax: 205-345-1761
Mailing address:
  • Phone: 205-345-1520
  • Fax: 205-345-1761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number00023999
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number00023999
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number00023999
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: