Provider Demographics
NPI:1508874603
Name:GHOBRIAL, GERGIS RAID (MD)
Entity Type:Individual
Prefix:
First Name:GERGIS
Middle Name:RAID
Last Name:GHOBRIAL
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 1:541 GREEN ACRE DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3603
Mailing Address - Country:US
Mailing Address - Phone:562-426-0147
Mailing Address - Fax:888-206-5318
Practice Address - Street 1:2650 ELM AVE
Practice Address - Street 2:SUITE 318
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1651
Practice Address - Country:US
Practice Address - Phone:562-426-0147
Practice Address - Fax:888-206-5318
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA533370208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A533370Medicaid
CA00A533370Medicaid
CAWA53337BMedicare PIN