Provider Demographics
NPI:1255339826
Name:GAMBOL, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GAMBOL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9126
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91309-0126
Mailing Address - Country:US
Mailing Address - Phone:818-709-8161
Mailing Address - Fax:818-709-8160
Practice Address - Street 1:1041 E YORBA LINDA BLVD STE 203
Practice Address - Street 2:
Practice Address - City:PLACENTIA
Practice Address - State:CA
Practice Address - Zip Code:92870-3762
Practice Address - Country:US
Practice Address - Phone:818-709-8161
Practice Address - Fax:818-709-8160
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87090207P00000X, 207PE0005X
FLME70844207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261062100Medicaid
FL606478700OtherDOL GRP#
FLME70844OtherLICENSE#
FL58630OtherGRP# 98513
CAG87090OtherLICENSE#
FL261062100Medicaid
FL606478700OtherDOL GRP#