Healthcare Provider Details

I. General information

NPI: 1386848612
Provider Name (Legal Business Name): BRIAN K GAMBLE, M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13521 SHERMAN WAY UNIT D
VAN NUYS CA
91405-2894
US

IV. Provider business mailing address

13521 SHERMAN WAY UNIT D
VAN NUYS CA
91405-2894
US

V. Phone/Fax

Practice location:
  • Phone: 818-786-5360
  • Fax: 818-786-5670
Mailing address:
  • Phone: 818-786-5360
  • Fax: 818-786-5670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberW20244A
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberA76121
License Number StateCA

VIII. Authorized Official

Name: DR. BRIAN KEITH GAMBLE
Title or Position: C.E.O.
Credential: M.D.
Phone: 818-786-5360