Basic Information
| Provider Information | |||||||||
| NPI: | 1639362858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EBALO-REYES | ||||||||
| FirstName: | GAUDELIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5025 KEYSTONE DR | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945367040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107974417 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6955 FOOTHILL BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946052426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105675800 | ||||||||
| FaxNumber: | 5105680225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A21820 | CA | Y | Other Service Providers | Specialist |
No ID Information.