Provider Demographics
NPI:1689102071
Name:GAMBLE, COLLIN
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9152 TAYLORSVILLE RD # 276
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-1702
Mailing Address - Country:US
Mailing Address - Phone:502-447-8786
Mailing Address - Fax:502-447-8623
Practice Address - Street 1:ONE AUDUBON PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1702
Practice Address - Country:US
Practice Address - Phone:502-447-8786
Practice Address - Fax:502-447-8623
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY578282085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100893170Medicaid
IN300075464Medicaid