Provider Demographics
NPI:1366863201
Name:GILBERT, CONSTANCE L (RD/CDE)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:L
Last Name:GILBERT
Suffix:
Gender:F
Credentials:RD/CDE
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:
Other - Last Name:KLATTE & TOBBEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:MSA 2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-8812
Practice Address - Fax:317-274-0133
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001298A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN145590083Medicare PIN
IN264430185Medicare PIN