Provider Demographics
NPI:1174863294
Name:MONDRAGON, GABRIEL SAUL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:SAUL
Last Name:MONDRAGON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S GLENN DR APT 8
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-7906
Mailing Address - Country:US
Mailing Address - Phone:805-469-4171
Mailing Address - Fax:
Practice Address - Street 1:125 W THOUSAND OAKS BLVD STE 500
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4462
Practice Address - Country:US
Practice Address - Phone:805-777-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD9927819390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program