Provider Demographics
NPI:1821869298
Name:GONCALVES DIERKS MACHADO, GABRIEL VICTOR
Entity Type:Individual
Prefix:MR
First Name:GABRIEL VICTOR
Middle Name:
Last Name:GONCALVES DIERKS MACHADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GABRIEL VICTOR
Other - Middle Name:
Other - Last Name:GONCALVES MACHADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 N 4TH ST APT 1/2
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-1316
Mailing Address - Country:US
Mailing Address - Phone:660-229-2466
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE HL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MO
Practice Address - Zip Code:63435-1299
Practice Address - Country:US
Practice Address - Phone:573-288-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer