Provider Demographics
NPI:1467448787
Name:ELTABBAKH, GAMAL H (MD)
Entity Type:Individual
Prefix:DR
First Name:GAMAL
Middle Name:H
Last Name:ELTABBAKH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 HINESBURG RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7612
Mailing Address - Country:US
Mailing Address - Phone:802-859-9500
Mailing Address - Fax:802-859-9944
Practice Address - Street 1:1060 HINESBURG RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7612
Practice Address - Country:US
Practice Address - Phone:802-859-9500
Practice Address - Fax:802-859-9944
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420009610207VG0400X, 207VX0201X
NY1994931207VG0400X, 207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01760585Medicaid
VTOVN1692Medicaid
NY01760585Medicaid
VTVN1692Medicare PIN
VTOVN1692Medicaid