Provider Demographics
NPI:1407872187
Name:GAMBOA, LAWRENCE SANTIAGO (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:SANTIAGO
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 1:10 CANTERBURY PL
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-7295
Mailing Address - Country:US
Mailing Address - Phone:408-848-4532
Mailing Address - Fax:
Practice Address - Street 1:10 CANTERBURY PL
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-7295
Practice Address - Country:US
Practice Address - Phone:408-848-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA066953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG20000Medicare UPIN
00A669530Medicare PIN
CACC366ZMedicare PIN