Provider Demographics
NPI:1245303353
Name:KOBAYASHI, GARY L (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:KOBAYASHI
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 1:145 THUNDER DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6010
Mailing Address - Country:US
Mailing Address - Phone:760-630-5464
Mailing Address - Fax:760-630-5476
Practice Address - Street 1:145 THUNDER DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6010
Practice Address - Country:US
Practice Address - Phone:760-630-5464
Practice Address - Fax:760-630-5476
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G584960Medicaid
CACB221768Medicare PIN
CA00G584960Medicaid