Healthcare Provider Details

I. General information

NPI: 1275086381
Provider Name (Legal Business Name): WILLIAM TRIBLE GATEWOOD JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW STREET EMERGENCY DEPARTMENT
MARIETTA OH
45750
US

IV. Provider business mailing address

401 MATTHEW STREET EMERGENCY DEPARTMENT
MARIETTA OH
45750-6401
US

V. Phone/Fax

Practice location:
  • Phone: 740-568-5669
  • Fax:
Mailing address:
  • Phone: 740-568-5669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2015024972
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102207275
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: