Provider Demographics
NPI:1366461188
Name:MYKONIATIS, GABRIELLE EILEEN (MD)
Entity type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:EILEEN
Last Name:MYKONIATIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GABRIELLE
Other - Middle Name:EILEEN
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10400 E ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80247-5104
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119282207R00000X
CODR.0072877207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO029553OtherKAISER COMMERCIAL NUMBER
ILR00340OtherMEDICARE PTAN