MEDICARE: DR. GUILLERMO GAMBOA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	152W00000X	Optometrist	IL
2	152WS0006X	Sports Vision Optometrist	IL
3	152WV0400X	Vision Therapy Optometrist	IL

General Provider Information

NPI Number	:	1982897005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GUILLERMO GAMBOA O.D.

Provider Business Mailing Address
First Line	:	10434 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2018
Country	:	US
Telephone Number	:	773-445-2700
Fax Number	:	773-445-2325

Provider Business Practice Location Address
First Line	:	10434 S KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2018
Country	:	US
Telephone Number	:	773-445-2700
Fax Number	:	773-445-2325

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	08/22/2007

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Directions to “ DR. GUILLERMO GAMBOA O.D.” Practice Location

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