Provider Demographics
NPI:1386374247
Name:MENNA, GABRIEL GINO (MD)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:GINO
Last Name:MENNA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CAMOMILE ST
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L4L 8S1
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7638 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3133
Practice Address - Country:US
Practice Address - Phone:833-515-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2025-03-10
Deactivation Date:2023-03-06
Deactivation Code:
Reactivation Date:2023-04-06
Provider Licenses
StateLicense IDTaxonomies
MI4301513153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine