Provider Demographics
NPI:1720428048
Name:KOOKOOTSEDES, GAYLE MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:MICHELLE
Last Name:KOOKOOTSEDES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GAYLE
Other - Middle Name:MICHELLE
Other - Last Name:GABRIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25401 CABOT RD. SUITE 101
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5631
Mailing Address - Country:US
Mailing Address - Phone:949-335-2372
Mailing Address - Fax:949-288-0341
Practice Address - Street 1:3633 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4011
Practice Address - Country:US
Practice Address - Phone:619-287-9730
Practice Address - Fax:619-287-4516
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62644207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75064Medicare UPIN