Provider Demographics
NPI:1972521458
Name:GOMBERG, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:GOMBERG
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 1:141 TRIUNFO CANYON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2525
Mailing Address - Country:US
Mailing Address - Phone:805-496-2229
Mailing Address - Fax:805-496-7479
Practice Address - Street 1:141 TRIUNFO CANYON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2525
Practice Address - Country:US
Practice Address - Phone:805-496-2229
Practice Address - Fax:805-496-7479
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20212174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14070Medicare ID - Type Unspecified