Provider Demographics
NPI:1285611699
Name:NILES, GABRIEL STEPHAN (MD)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:STEPHAN
Last Name:NILES
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 1:12555 W JEFFERSON BLVD # 301
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-7032
Mailing Address - Country:US
Mailing Address - Phone:424-443-5555
Mailing Address - Fax:424-443-5550
Practice Address - Street 1:12555 W JEFFERSON BLVD STE 301
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-7032
Practice Address - Country:US
Practice Address - Phone:424-443-5555
Practice Address - Fax:424-443-5550
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD6030955207Q00000X
CAA100831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2045010OtherWA MEDICAID PROVIDER ID
WAG8940666OtherMEDICARE PTAN