Healthcare Provider Details

I. General information

NPI: 1154583177
Provider Name (Legal Business Name): BRANDON R. GUMBINER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E 1ST ST STE 310
DIXON IL
61021
US

IV. Provider business mailing address

215 E 1ST ST STE 310
DIXON IL
61021-3190
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-5801
  • Fax: 815-285-5699
Mailing address:
  • Phone: 815-285-5801
  • Fax: 815-285-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005377
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07001081
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: