Provider Demographics
NPI:1396849907
Name:GALE, GORDON B
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:B
Last Name:GALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3691 RUTGER AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2515
Mailing Address - Country:US
Mailing Address - Phone:314-977-6828
Mailing Address - Fax:314-977-6872
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-268-4101
Practice Address - Fax:314-577-5379
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR78492080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology