Healthcare Provider Details

I. General information

NPI: 1730893033
Provider Name (Legal Business Name): ANDRES J GAMBOA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9634 S PULASKI RD
OAK LAWN IL
60453-3391
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-4800
  • Fax: 708-423-4843
Mailing address:
  • Phone: 630-575-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070027145
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: