Provider Demographics
NPI:1922056464
Name:MAMAUAG, GILBERT M (MD)
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:M
Last Name:MAMAUAG
Suffix:
Gender:M
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0370
Mailing Address - Country:US
Mailing Address - Phone:859-227-7666
Mailing Address - Fax:606-864-4774
Practice Address - Street 1:346 BEECHWOOD DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-5403
Practice Address - Country:US
Practice Address - Phone:859-227-7666
Practice Address - Fax:606-864-4774
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31417207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000526857OtherANTHEM BCBS
KY6431417200Medicaid
KY000000525342OtherANTHEM BCBS
KYF93304Medicare UPIN
KY000000525342OtherANTHEM BCBS
KY00280002Medicare PIN