Provider Demographics
NPI:1700205275
Name:BENJAMIN T. GAMBOA,M.D. L.L.C.
Entity Type:Organization
Organization Name:BENJAMIN T. GAMBOA,M.D. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:GAMBOA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-873-0299
Mailing Address - Street 1:135 S WAKEA AVE
Mailing Address - Street 2:STE 107
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-1385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 S WAKEA AVE
Practice Address - Street 2:STE 107
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1385
Practice Address - Country:US
Practice Address - Phone:808-873-0299
Practice Address - Fax:808-873-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 8771207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty