Healthcare Provider Details

I. General information

NPI: 1982689295
Provider Name (Legal Business Name): WARREN REGH C. GABRILLO III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 N 13TH AVE A
UPLAND CA
91786-4946
US

IV. Provider business mailing address

631 N 13TH AVE A
UPLAND CA
91786-4946
US

V. Phone/Fax

Practice location:
  • Phone: 909-982-2088
  • Fax: 909-982-2058
Mailing address:
  • Phone: 909-982-2088
  • Fax: 909-982-2058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA51794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: