=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154583177
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON R. GUMBINER DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2008
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 E 1ST ST STE 310
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-285-5801
-----------------------------------------------------
Fax | 815-285-5699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 E 1ST ST STE 310
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-285-5801
-----------------------------------------------------
Fax | 815-285-5699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 016005377
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 07001081
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------