Healthcare Provider Details

I. General information

NPI: 1629546437
Provider Name (Legal Business Name): RAFAEL ANTONIO GAMBA JR. OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112A RIVERSTONE PKWY
CANTON GA
30114-2448
US

IV. Provider business mailing address

PO BOX 4398
CANTON GA
30114-0017
US

V. Phone/Fax

Practice location:
  • Phone: 770-874-2020
  • Fax: 470-785-2795
Mailing address:
  • Phone: 770-874-2020
  • Fax: 470-785-2795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003130
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: