Healthcare Provider Details

I. General information

NPI: 1487593257
Provider Name (Legal Business Name): OMAR ENRIQUE GAMBOA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4865 TRUXTUN AVE
BAKERSFIELD CA
93309-0605
US

IV. Provider business mailing address

4865 TRUXTUN AVE
BAKERSFIELD CA
93309-0605
US

V. Phone/Fax

Practice location:
  • Phone: 661-634-0789
  • Fax:
Mailing address:
  • Phone: 661-634-0789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number106E00000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: