Healthcare Provider Details

I. General information

NPI: 1407952096
Provider Name (Legal Business Name): JORGE CABRERA GABILONDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT. 358
VANCOUVER WA
98683-9324
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-2730
  • Fax: 360-414-2739
Mailing address:
  • Phone: 360-729-1462
  • Fax: 360-729-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60544064
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberE4842
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberTD60544072
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD60544064
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: