Healthcare Provider Details

I. General information

NPI: 1619820735
Provider Name (Legal Business Name): ELIZABETH GAMBOA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2026
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 3RD AVE
BRONX NY
10457-2594
US

IV. Provider business mailing address

3942 CONDE ST
SAN DIEGO CA
92110-2815
US

V. Phone/Fax

Practice location:
  • Phone: 832-363-8154
  • Fax: 832-363-8154
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberP140664
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: