Provider Demographics
NPI:1528013836
Name:GIBELLATO, CHARLES MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MATTHEW
Last Name:GIBELLATO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY 200
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:8200 MEADOWBRIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2331
Practice Address - Country:US
Practice Address - Phone:804-730-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237142208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010133360Medicaid
VAH84864Medicare UPIN
VA005575S41Medicare PIN