Provider Demographics
NPI:1275948044
Name:GAMBOA, FAYE THERESE (OD)
Entity Type:Individual
Prefix:
First Name:FAYE THERESE
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3432
Mailing Address - Country:US
Mailing Address - Phone:847-787-1187
Mailing Address - Fax:847-789-7181
Practice Address - Street 1:1745 ORCHARD LN
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3432
Practice Address - Country:US
Practice Address - Phone:847-787-1187
Practice Address - Fax:847-789-7181
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist