Provider Demographics
NPI:1689607897
Name:JOHN E GAMBOA MD PLLC
Entity Type:Organization
Organization Name:JOHN E GAMBOA MD PLLC
Other - Org Name:CANCER CENTER OF IDAHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAMBOA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-672-1000
Mailing Address - Street 1:PO BOX 9589
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-4589
Mailing Address - Country:US
Mailing Address - Phone:208-472-8122
Mailing Address - Fax:208-344-1926
Practice Address - Street 1:9357 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9752
Practice Address - Country:US
Practice Address - Phone:208-672-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378401Medicare PIN