Provider Demographics
NPI:1033187125
Name:GAMBIRAZIO, CARLOS A (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:GAMBIRAZIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2479
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-7624
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046677A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200145840Medicaid
IN8155500582OtherMEDICARE PTAN
IN000000282913OtherANTHEM PROVIDER NUMBER
ING12588Medicare UPIN
IN815150GMedicare PIN