Provider Demographics
NPI:1558633628
Name:DARIN GAMBLES
Entity Type:Organization
Organization Name:DARIN GAMBLES
Other - Org Name:PARKWAY FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMBLES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-785-2555
Mailing Address - Street 1:1495 PARKWAY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1638
Mailing Address - Country:US
Mailing Address - Phone:208-785-2555
Mailing Address - Fax:208-785-9952
Practice Address - Street 1:1495 PARKWAY DR
Practice Address - Street 2:SUITE B
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1638
Practice Address - Country:US
Practice Address - Phone:208-785-2555
Practice Address - Fax:208-785-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-153213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1790768174Medicaid
ID1790768174Medicaid
ID20000034Medicare PIN