Healthcare Provider Details

I. General information

NPI: 1386671394
Provider Name (Legal Business Name): MICHAEL JOHN GAMBELLO MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

IV. Provider business mailing address

2165 N DECATUR RD EMORY CLINIC DEPARTMENT OF HUMAN GENETICS
DECATUR GA
30033-5307
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-8570
  • Fax: 404-778-8562
Mailing address:
  • Phone: 404-778-8570
  • Fax: 404-778-8562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number67568
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberL3304
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: