Provider Demographics
NPI:1891990271
Name:GAMMON, RACHELLE L (DO)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:L
Last Name:GAMMON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 73RD ST
Mailing Address - Street 2:SUITE 30
Mailing Address - City:WINDSOR HEIGHTS
Mailing Address - State:IA
Mailing Address - Zip Code:50312-1024
Mailing Address - Country:US
Mailing Address - Phone:515-224-4993
Mailing Address - Fax:515-224-1505
Practice Address - Street 1:974 73RD ST
Practice Address - Street 2:SUITE 30
Practice Address - City:WINDSOR HEIGHTS
Practice Address - State:IA
Practice Address - Zip Code:50312-1024
Practice Address - Country:US
Practice Address - Phone:515-224-4993
Practice Address - Fax:515-224-1505
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3803208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1891990271Medicaid
IAI20884Medicare PIN