Provider Demographics
NPI:1558362947
Name:GAMBACH, JEFFREY RONALD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RONALD
Last Name:GAMBACH
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 1:2800 CAMPUS DR
Mailing Address - Street 2:#10
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2645
Mailing Address - Country:US
Mailing Address - Phone:763-559-2171
Mailing Address - Fax:763-694-9000
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-559-2171
Practice Address - Fax:763-694-9000
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN465492085R0202X, 2085U0001X, 2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN714452100Medicaid
300003404Medicare ID - Type Unspecified
MN714452100Medicaid