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General NPI Number Information
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NPI Number | 1982897005
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Entity Type | Individual
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Provider Name | GUILLERMO GAMBOA O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/22/2007
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Last Update Date | 08/22/2007
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Provider Practice Location Address
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Address Line | 10434 S KEDZIE AVE
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City | CHICAGO
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State | IL
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Zip | 60655-2018
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Country | US
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Telephone | 773-445-2700
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Fax | 773-445-2325
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Provider Business Mailing Address
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Address Line | 10434 S KEDZIE AVE
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City | CHICAGO
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State | IL
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Zip | 60655-2018
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Country | US
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Telephone | 773-445-2700
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Fax | 773-445-2325
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 152WS0006X
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Taxonomy Name | Sports Vision Optometrist
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License Number |
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number |
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License Number State | IL
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