Provider Demographics
NPI:1376681213
Name:BAMBERGER, GINA C (DO)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:C
Last Name:BAMBERGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 N CORONA ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-7644
Mailing Address - Country:US
Mailing Address - Phone:719-365-7100
Mailing Address - Fax:719-365-7109
Practice Address - Street 1:1730 N CORONA ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7644
Practice Address - Country:US
Practice Address - Phone:719-365-7100
Practice Address - Fax:719-365-7109
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36186207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01361864Medicaid
COCOA109697Medicare PIN
CO01361864Medicaid