Provider Demographics
NPI:1811289317
Name:BOXIDARA, INC.
Entity type:Organization
Organization Name:BOXIDARA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GAMBOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-709-8161
Mailing Address - Street 1:PO BOX 9126
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91309-0126
Mailing Address - Country:US
Mailing Address - Phone:818-709-8161
Mailing Address - Fax:818-709-8160
Practice Address - Street 1:38660 MEDICAL CENTER DR STE A150
Practice Address - Street 2:C/O PALMDALE MED. CTR. WOUND CARE CLINIC
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4385
Practice Address - Country:US
Practice Address - Phone:818-709-8161
Practice Address - Fax:818-709-8160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67090207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTIN#