Healthcare Provider Details

I. General information

NPI: 1275621963
Provider Name (Legal Business Name): LARRY KYLE GAMBRELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6880 PALM AVENUE
SEBASTOPOL CA
95472
US

IV. Provider business mailing address

6880 PALM AVE
SEBASTOPOL CA
95472-4270
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-7628
  • Fax: 707-823-1521
Mailing address:
  • Phone: 707-823-7628
  • Fax: 707-823-1521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number20A9837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: