Healthcare Provider Details

I. General information

NPI: 1801832167
Provider Name (Legal Business Name): GREGORY R GAMBLA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 02/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 FLETCHER DR STE 202
ELGIN IL
60123-4747
US

IV. Provider business mailing address

39W357 BAKER DR
GENEVA IL
60134-6114
US

V. Phone/Fax

Practice location:
  • Phone: 847-888-1300
  • Fax: 847-888-1341
Mailing address:
  • Phone: 630-208-9848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036098608
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: