Provider Demographics
NPI:1154583177
Name:GUMBINER, BRANDON R (DPM)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:R
Last Name:GUMBINER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 1ST ST STE 310
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3190
Mailing Address - Country:US
Mailing Address - Phone:815-285-5801
Mailing Address - Fax:815-285-5699
Practice Address - Street 1:215 E 1ST ST STE 310
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5801
Practice Address - Fax:815-285-5699
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005377213ES0103X
IN07001081213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005377Medicaid
IN508770006OtherMEDICARE
ILF400482004OtherMEDICARE PTAN