Healthcare Provider Details

I. General information

NPI: 1760779672
Provider Name (Legal Business Name): DWAYNE DOUGLAS GBELIA SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 S HIGLEY RD SUITE 114-171
GILBERT AZ
85297-5436
US

IV. Provider business mailing address

3317 S HIGLEY RD SUITE 114-171
GILBERT AZ
85297-5436
US

V. Phone/Fax

Practice location:
  • Phone: 480-620-4498
  • Fax: 888-411-9856
Mailing address:
  • Phone: 480-620-4498
  • Fax: 888-411-9856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number09-137
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: