Healthcare Provider Details

I. General information

NPI: 1205766474
Provider Name (Legal Business Name): GABRIEL FABIAN OLIVARES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W VISTA WAY STE 407
VISTA CA
92083-5714
US

IV. Provider business mailing address

550 W VISTA WAY STE 407
VISTA CA
92083-5714
US

V. Phone/Fax

Practice location:
  • Phone: 760-758-1092
  • Fax: 760-560-2098
Mailing address:
  • Phone: 760-758-1092
  • Fax: 760-560-2098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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: