Provider Demographics
NPI:1790768174
Name:GAMBLES, DARIN (DPM)
Entity Type:Individual
Prefix:
First Name:DARIN
Middle Name:
Last Name:GAMBLES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 PARKWAY DR
Mailing Address - Street 2:STE 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:STE 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP153213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID800772179Medicaid
ID20000033Medicare PIN
ID800772179Medicaid
U73210Medicare UPIN