Provider Demographics
NPI:1346459088
Name:GAMBILL, BOPHA TIEM (MPT)
Entity Type:Individual
Prefix:
First Name:BOPHA
Middle Name:TIEM
Last Name:GAMBILL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20463 E 46TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8764
Mailing Address - Country:US
Mailing Address - Phone:918-712-7805
Mailing Address - Fax:918-712-7813
Practice Address - Street 1:4815 S HARVARD AVE STE 455
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3078
Practice Address - Country:US
Practice Address - Phone:918-712-7805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3721225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist