=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609083435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA OPHTHALMIC LASER ASSOCIATES, MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 W JOAQUIN AVE SUITE 250
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-895-9657
-----------------------------------------------------
Fax | 510-895-9680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 W JOAQUIN AVE SUITE 250
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-895-9657
-----------------------------------------------------
Fax | 510-895-9680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. HAROLD GAMBILL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 408-398-6066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------