Provider Demographics
NPI:1174181689
Name:GABRIEL ZACHARIA REAGLE DO
Entity Type:Organization
Organization Name:GABRIEL ZACHARIA REAGLE DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:ZACHARIA
Authorized Official - Last Name:REAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:805-503-5312
Mailing Address - Street 1:4554 WAVERTREE ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7831
Mailing Address - Country:US
Mailing Address - Phone:805-503-5312
Mailing Address - Fax:
Practice Address - Street 1:1400 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5906
Practice Address - Country:US
Practice Address - Phone:805-503-5312
Practice Address - Fax:805-973-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-30
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A10912OtherDO LICENSE