Healthcare Provider Details

I. General information

NPI: 1265445050
Provider Name (Legal Business Name): PAUL T GAMBARDELLA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 MAIN ST UNIT 110
YALESVILLE CT
06492-2279
US

IV. Provider business mailing address

329 MAIN ST UNIT 110
YALESVILLE CT
06492-2279
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-6677
  • Fax: 203-294-9784
Mailing address:
  • Phone: 203-265-6677
  • Fax: 203-294-9784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000547
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: