Healthcare Provider Details

I. General information

NPI: 1902847932
Provider Name (Legal Business Name): RUDOLPH-BEAR A GAMBOA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 3RD AVE
CHULA VISTA CA
91910-5616
US

IV. Provider business mailing address

525 3RD AVE
CHULA VISTA CA
91910-5616
US

V. Phone/Fax

Practice location:
  • Phone: 619-585-4000
  • Fax: 619-585-4005
Mailing address:
  • Phone: 619-585-4000
  • Fax: 619-585-4005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA68222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: