Provider Demographics
NPI:1275621963
Name:GAMBRELL, LARRY KYLE (DO)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:KYLE
Last Name:GAMBRELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6880 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4270
Mailing Address - Country:US
Mailing Address - Phone:707-823-7628
Mailing Address - Fax:707-823-1521
Practice Address - Street 1:6880 PALM AVENUE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472
Practice Address - Country:US
Practice Address - Phone:707-823-7628
Practice Address - Fax:707-823-1521
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9837207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA107813OtherMEDICARE