Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | 2016028884 | MO |
Y | 208200000X | Surgeon | 2016028884 | MO |
Y | 208600000X | Surgeon | 2016028884 | MO |
NPI | 1154703841 |
---|---|
Provider Name | Preston Mangum Gilbert |
First Address | Saint Louis, MO 63122-3313 |
Second Address | Saint Louis, MO 63122-3313 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2015 |
Last Update Date | 29/08/2016 |