Provider Demographics
NPI:1265020069
Name:GAMBOA, IVONNE SUSANA (MD)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:SUSANA
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1094 MILITARY TRL
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7021
Mailing Address - Country:US
Mailing Address - Phone:561-622-6111
Mailing Address - Fax:855-215-9930
Practice Address - Street 1:1094 MILITARY TRL
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7021
Practice Address - Country:US
Practice Address - Phone:561-622-6111
Practice Address - Fax:855-215-9930
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37767208D00000X
NJNJDCATEMP-037072208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty