Provider Demographics
NPI:1619374980
Name:GAMBOA, MARK JOSEPH VILLANUEVA
Entity Type:Individual
Prefix:
First Name:MARK JOSEPH
Middle Name:VILLANUEVA
Last Name:GAMBOA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7345 WOODLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278
Mailing Address - Country:US
Mailing Address - Phone:317-286-2885
Mailing Address - Fax:317-536-3097
Practice Address - Street 1:7 TIMMERMAN AVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13452-1017
Practice Address - Country:US
Practice Address - Phone:518-568-5037
Practice Address - Fax:518-568-7505
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CT10430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist