Provider Demographics
NPI:1447577309
Name:GAMBARDELLA, GABRIEL VINCENT (DPM)
Entity Type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:VINCENT
Last Name:GAMBARDELLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1 NORTHWESTERN DRIVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3400
Mailing Address - Country:US
Mailing Address - Phone:860-243-2951
Mailing Address - Fax:860-243-5790
Practice Address - Street 1:1 NORTHWESTERN DRIVE
Practice Address - Street 2:SUITE 301
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3400
Practice Address - Country:US
Practice Address - Phone:860-243-2951
Practice Address - Fax:860-243-5790
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0000895213ES0103X, 213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1447577309Medicaid
CTD400086746Medicare PIN