Provider Demographics
NPI:1629546437
Name:GAMBA, RAFAEL ANTONIO JR (OD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:ANTONIO
Last Name:GAMBA
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4398
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-0017
Mailing Address - Country:US
Mailing Address - Phone:770-874-2020
Mailing Address - Fax:470-785-2795
Practice Address - Street 1:112A RIVERSTONE PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2448
Practice Address - Country:US
Practice Address - Phone:770-874-2020
Practice Address - Fax:470-785-2795
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003130152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist