Provider Demographics
NPI:1366739468
Name:GAMBOA VELEZ, IVAN J (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:J
Last Name:GAMBOA VELEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IVAN
Other - Middle Name:J
Other - Last Name:GAMBOA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-300-1076
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:5428 ODONOVAN DR STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4387
Practice Address - Country:US
Practice Address - Phone:225-300-1076
Practice Address - Fax:225-300-1080
Is Sole Proprietor?:No
Enumeration Date:2011-07-09
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125059415207R00000X
LA301598207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine