Healthcare Provider Details

I. General information

NPI: 1386374247
Provider Name (Legal Business Name): GABRIEL GINO MENNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date: 03/06/2023
Reactivation Date: 04/06/2023

III. Provider practice location address

7638 N MILWAUKEE AVE
NILES IL
60714-3133
US

IV. Provider business mailing address

102 CAMOMILE ST
WOODBRIDGE ONTARIO
L4L 8S1
CA

V. Phone/Fax

Practice location:
  • Phone: 833-515-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301513153
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: