Healthcare Provider Details

I. General information

NPI: 1598620668
Provider Name (Legal Business Name): LUIS FERNANDO GAMBOA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9340 S 65TH EAST PL
TULSA OK
74133-5336
US

IV. Provider business mailing address

9340 S 65TH EAST PL
TULSA OK
74133-5336
US

V. Phone/Fax

Practice location:
  • Phone: 918-519-8751
  • Fax:
Mailing address:
  • Phone: 918-519-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: