Healthcare Provider Details

I. General information

NPI: 1447577309
Provider Name (Legal Business Name): GABRIEL VINCENT GAMBARDELLA D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 NORTHWESTERN DRIVE SUITE 301
BLOOMFIELD CT
06002-3400
US

IV. Provider business mailing address

1 NORTHWESTERN DRIVE SUITE 301
BLOOMFIELD CT
06002-3400
US

V. Phone/Fax

Practice location:
  • Phone: 860-243-2951
  • Fax: 860-243-5790
Mailing address:
  • Phone: 860-243-2951
  • Fax: 860-243-5790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0000895
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0000895
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: