Provider Demographics
NPI:1982689295
Name:GABRILLO, WARREN REGH C III (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN REGH
Middle Name:C
Last Name:GABRILLO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:631 N 13TH AVE
Mailing Address - Street 2:A
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4946
Mailing Address - Country:US
Mailing Address - Phone:909-982-2088
Mailing Address - Fax:909-982-2058
Practice Address - Street 1:631 N 13TH AVE
Practice Address - Street 2:A
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4946
Practice Address - Country:US
Practice Address - Phone:909-982-2088
Practice Address - Fax:909-982-2058
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA517941Medicaid
CAG14231Medicare UPIN
CAA517941Medicaid