Provider Demographics
NPI:1265508980
Name:GAMBOA, EDGAR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:
Last Name:GAMBOA
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 1:576 HARTNELL ST
Mailing Address - Street 2:STE 200
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-2834
Mailing Address - Country:US
Mailing Address - Phone:831-324-0176
Mailing Address - Fax:
Practice Address - Street 1:243 GREEN VALLEY RD
Practice Address - Street 2:STE. D
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3133
Practice Address - Country:US
Practice Address - Phone:831-724-7874
Practice Address - Fax:831-724-4339
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41857208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C418570Medicaid
CAA37688Medicare UPIN
CA00C418570Medicaid