Healthcare Provider Details

I. General information

NPI: 1467236281
Provider Name (Legal Business Name): GABRIEL ISAAC SAMARA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SHAFFER RD BLDG 1
SANTA CRUZ CA
95060-5761
US

IV. Provider business mailing address

113 CYPRESS AVE APT B
SANTA CRUZ CA
95062-3710
US

V. Phone/Fax

Practice location:
  • Phone: 831-888-6007
  • Fax:
Mailing address:
  • Phone: 831-529-5034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-HXIWJU
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: