MEDICARE: DR. KENNETH RAY GAMBLIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	17345	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063418408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH RAY GAMBLIN MD

Provider Business Mailing Address
First Line	:	963 E COLORADO AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-3776
Country	:	US
Telephone Number	:	719-578-1119
Fax Number	:	719-578-1487

Provider Business Practice Location Address
First Line	:	963 E COLORADO AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-3776
Country	:	US
Telephone Number	:	719-578-1119
Fax Number	:	719-578-1487

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	08/05/2009

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