Provider Demographics
NPI:1386848612
Name:BRIAN K GAMBLE, M.D. INC
Entity Type:Organization
Organization Name:BRIAN K GAMBLE, M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-786-5360
Mailing Address - Street 1:13521 SHERMAN WAY
Mailing Address - Street 2:UNIT D
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2894
Mailing Address - Country:US
Mailing Address - Phone:818-786-5360
Mailing Address - Fax:818-786-5670
Practice Address - Street 1:13521 SHERMAN WAY
Practice Address - Street 2:UNIT D
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2894
Practice Address - Country:US
Practice Address - Phone:818-786-5360
Practice Address - Fax:818-786-5670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW20244A207Q00000X
CAA761212084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA76121OtherSTATE LICENSE
CAA76121OtherSTATE LICENSE