Provider Demographics
NPI:1902847932
Name:GAMBOA, RUDOLPH-BEAR A (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH-BEAR
Middle Name:A
Last Name:GAMBOA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5616
Mailing Address - Country:US
Mailing Address - Phone:619-585-4000
Mailing Address - Fax:619-585-4005
Practice Address - Street 1:525 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5616
Practice Address - Country:US
Practice Address - Phone:619-585-4000
Practice Address - Fax:619-585-4005
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68222207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI49105Medicare UPIN