Basic Information
| Provider Information | |||||||||
| NPI: | 1114019486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LABORADA | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | GO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8188 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923751388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097905071 | ||||||||
| FaxNumber: | 9097905774 | ||||||||
| Practice Location | |||||||||
| Address1: | 3865 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925033919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513525490 | ||||||||
| FaxNumber: | 9513525368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | A87019 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A870190 | 05 | CA | MEDICAID |