Provider Demographics
NPI:1639362858
Name:EBALO-REYES, GAUDELIA (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUDELIA
Middle Name:
Last Name:EBALO-REYES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 KEYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-7040
Mailing Address - Country:US
Mailing Address - Phone:510-797-4417
Mailing Address - Fax:
Practice Address - Street 1:6955 FOOTHILL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2426
Practice Address - Country:US
Practice Address - Phone:510-567-5800
Practice Address - Fax:510-568-0225
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21820174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22784Medicare UPIN