Provider Demographics
NPI:1578903118
Name:GAMBRELL, CHADWICK E (DO)
Entity Type:Individual
Prefix:DR
First Name:CHADWICK
Middle Name:E
Last Name:GAMBRELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-1452
Mailing Address - Country:US
Mailing Address - Phone:606-337-5215
Mailing Address - Fax:606-337-1128
Practice Address - Street 1:121 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1661
Practice Address - Country:US
Practice Address - Phone:606-337-5215
Practice Address - Fax:606-337-1128
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KYR3393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0169Medicare PIN