1922056464 NPI number — GILBERT M MAMAUAG M.D.

Table of content: GILBERT M MAMAUAG M.D. (NPI 1922056464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922056464 NPI number — GILBERT M MAMAUAG M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAMAUAG
Provider First Name:
GILBERT
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922056464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-0370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-227-7666
Provider Business Mailing Address Fax Number:
606-864-4774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
346 BEECHWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONDON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40744-5403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-227-7666
Provider Business Practice Location Address Fax Number:
606-864-4774
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  31417 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 31417 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000526857 . This is a "ANTHEM BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 6431417200 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000525342 . This is a "ANTHEM BCBS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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