Healthcare Provider Details

I. General information

NPI: 1851860142
Provider Name (Legal Business Name): GABRIEL PERDOMO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 SAN BERNARDINO RD
UPLAND CA
91786-4920
US

IV. Provider business mailing address

999 SAN BERNARDINO RD
UPLAND CA
91786-4920
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-2811
  • Fax: 909-579-6682
Mailing address:
  • Phone: 909-985-2811
  • Fax: 909-579-6682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9394253
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: