Provider Demographics
NPI:1558113076
Name:JOHN GAMBRILL JR.
Entity Type:Organization
Organization Name:JOHN GAMBRILL JR.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GIDGET
Authorized Official - Middle Name:DEMETRUIS
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-804-9858
Mailing Address - Street 1:715 MAIDEN CHOICE LN
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5999
Mailing Address - Country:US
Mailing Address - Phone:410-247-5602
Mailing Address - Fax:
Practice Address - Street 1:715 MAIDEN CHOICE LN
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5999
Practice Address - Country:US
Practice Address - Phone:410-247-5602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty