Provider Demographics
NPI:1295995439
Name:GAMBLE, MARYANN CECELIA KATHERINE (MD)
Entity type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:CECELIA KATHERINE
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARYANN
Other - Middle Name:CECELIA
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3107 BONAVENTURE CT
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-3100
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9297207Q00000X
CODR.0075806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201845903Medicaid
TX201845902Medicaid
TXP01050719Medicare PIN
TXTXB139023Medicare PIN
TXTXB139025Medicare PIN