Healthcare Provider Details

I. General information

NPI: 1568478436
Provider Name (Legal Business Name): BRIAN KEITH GAMBLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BRIAN KEITH GAMBLE M.D

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 RIVERSIDE DR SUITE 16
TOLUCA LAKE CA
91602-2384
US

IV. Provider business mailing address

10701 RIVERSIDE DR 16
TOLUCA LAKE CA
91602-2384
US

V. Phone/Fax

Practice location:
  • Phone: 818-985-1221
  • Fax:
Mailing address:
  • Phone: 818-985-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberA76121
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License NumberA76121
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA76121
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA76121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: