MEDICARE: DR. JONATHAN DAVID GAMBRELL M.D.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207W00000X	Ophthalmology Physician	01072743A	IN
3	207W00000X	Ophthalmology Physician	47120	KY

General Provider Information

NPI Number	:	1831326552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN DAVID GAMBRELL M.D.

Provider Business Mailing Address
First Line	:	3810 SPRINGHURST BLVD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40241-6100
Country	:	US
Telephone Number	:	502-897-9881
Fax Number	:

Provider Business Practice Location Address
First Line	:	3810 SPRINGHURST BLVD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40241-6100
Country	:	US
Telephone Number	:	502-897-9881
Fax Number	:

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

Provider Enumeration Date	:	06/20/2009
Last Update Date	:	01/26/2015

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