Provider Demographics
NPI:1194804146
Name:GUMBS, VINCENT LEONARD (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:LEONARD
Last Name:GUMBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16542 VENTURA BLVD.
Mailing Address - Street 2:SUITE #302
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-5030
Mailing Address - Country:US
Mailing Address - Phone:818-701-9211
Mailing Address - Fax:818-701-6327
Practice Address - Street 1:16542 VENTURA BLVD.
Practice Address - Street 2:SUITE #302
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-5030
Practice Address - Country:US
Practice Address - Phone:818-701-9211
Practice Address - Fax:818-701-6327
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A39647Medicaid
CAA39647Medicare ID - Type Unspecified
CAA28937Medicare UPIN