Provider Demographics
NPI:1215941547
Name:GAMEL, GRANT RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:GRANT
Middle Name:RICHARD
Last Name:GAMEL
Suffix:
Gender:M
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:PO BOX 106002
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-6002
Mailing Address - Country:US
Mailing Address - Phone:352-867-8898
Mailing Address - Fax:352-732-6282
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:352-867-8898
Practice Address - Fax:352-732-6282
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006312207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371050500Medicaid
FL80629OtherBLUE CROSS BLUE SHIELD
FL80629OtherBLUE CROSS BLUE SHIELD
FL80629WMedicare ID - Type Unspecified