Provider Demographics
NPI:1912120114
Name:GABRIELE, MARY E (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:GABRIELE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 E WHITEAKER AVE
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97424-1648
Mailing Address - Country:US
Mailing Address - Phone:541-649-1450
Mailing Address - Fax:541-649-1110
Practice Address - Street 1:502 E WHITEAKER AVE
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-1648
Practice Address - Country:US
Practice Address - Phone:541-649-1450
Practice Address - Fax:541-649-1110
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28280207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR279279Medicaid
OR279279Medicaid