Provider Demographics
NPI:1568478436
Name:GAMBLE, BRIAN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BRIAN
Other - Middle Name:KEITH
Other - Last Name:GAMBLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10701 RIVERSIDE DR
Mailing Address - Street 2:16
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2384
Mailing Address - Country:US
Mailing Address - Phone:818-985-1221
Mailing Address - Fax:
Practice Address - Street 1:10701 RIVERSIDE DR
Practice Address - Street 2:SUITE 16
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2384
Practice Address - Country:US
Practice Address - Phone:818-985-1221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA761212085U0001X, 207UN0902X, 2085R0202X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice