Healthcare Provider Details

I. General information

NPI: 1275615718
Provider Name (Legal Business Name): JOSE GAMBOA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S ANAHEIM BLVD STE 214
ANAHEIM CA
92805-5808
US

IV. Provider business mailing address

PO BOX 6334
ANAHEIM CA
92816-0334
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-6363
  • Fax: 714-935-8112
Mailing address:
  • Phone: 714-935-6363
  • Fax: 714-935-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA45291
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: