Provider Demographics
NPI:1750529624
Name:GAMBOA, JOVA (MED)
Entity type:Individual
Prefix:
First Name:JOVA
Middle Name:
Last Name:GAMBOA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CHESTNUT ST APT 1
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-1509
Mailing Address - Country:US
Mailing Address - Phone:978-235-2813
Mailing Address - Fax:
Practice Address - Street 1:105 VICTORY RD
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-3518
Practice Address - Country:US
Practice Address - Phone:617-371-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS98086223174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist