Basic Information
Provider Information | |||||||||
NPI: | 1023121183 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GABHART | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | LEW | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHERUBIN | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | LEW | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5525 GROSSMONT CENTER DR | ||||||||
Address2: |   | ||||||||
City: | LA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 919423009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8584992600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5525 GROSSMONT CENTER DR | ||||||||
Address2: |   | ||||||||
City: | LA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 919423009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8584992600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A68275 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 00A682750 | 05 | CA |   | MEDICAID |