Healthcare Provider Details

I. General information

NPI: 1679145635
Provider Name (Legal Business Name): MICAH THOMAS GAMBLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2021
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MOHOULI ST STE 200
HILO HI
96720-7210
US

IV. Provider business mailing address

45 MOHOULI ST STE 200
HILO HI
96720-7210
US

V. Phone/Fax

Practice location:
  • Phone: 808-932-4215
  • Fax:
Mailing address:
  • Phone: 808-932-4215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-25510
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: