Provider Demographics
NPI:1386671394
Name:GAMBELLO, MICHAEL JOHN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:GAMBELLO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 N DECATUR RD
Mailing Address - Street 2:EMORY CLINIC DEPARTMENT OF HUMAN GENETICS
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5307
Mailing Address - Country:US
Mailing Address - Phone:404-778-8570
Mailing Address - Fax:404-778-8562
Practice Address - Street 1:2165 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5307
Practice Address - Country:US
Practice Address - Phone:404-778-8570
Practice Address - Fax:404-778-8562
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67568207SG0201X
TXL3304207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003122764AMedicaid
TN147519602OtherCSHCN
TX147519602Medicaid
TX8135N6OtherBCBS
TN147519602OtherCSHCN
GA003122764AMedicaid
TX8135N6OtherBCBS
TX370020673Medicare PIN