Healthcare Provider Details

I. General information

NPI: 1952353542
Provider Name (Legal Business Name): ROBERT CLAYTON GAMBRELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 N BELAIR RD STE 2B
EVANS GA
30809-3190
US

IV. Provider business mailing address

4381 DEERWOOD LN
EVANS GA
30809-4605
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36747
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number28706
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036747
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: