Provider Demographics
NPI:1790950079
Name:GAMBLE, SUSAN REBECCA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:REBECCA
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-9554
Mailing Address - Country:US
Mailing Address - Phone:707-963-2002
Mailing Address - Fax:
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-963-2002
Practice Address - Fax:707-963-2003
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 109612207R00000X
CAA123317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FL14E2GOtherBCBS
FLPENDINGMedicare PIN