Basic Information
| Provider Information | |||||||||
| NPI: | 1851754139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROKOP | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DICKSON | ||||||||
| OtherFirstName: | GABRIELLE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 416 COLEGATE DR BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457509549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405684814 | ||||||||
| FaxNumber: | 7403743165 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E 8TH ST STE 142 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457503382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403734111 | ||||||||
| FaxNumber: | 7403734860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2016 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35.138663 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.