Provider Demographics
NPI:1962622803
Name:WARREN REGH C. GABRILLO III M.D. INC.
Entity type:Organization
Organization Name:WARREN REGH C. GABRILLO III M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN REGH
Authorized Official - Middle Name:CAMOTES
Authorized Official - Last Name:GABRILLO
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:909-982-2088
Mailing Address - Street 1:631 N 13TH AVE
Mailing Address - Street 2:A
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4946
Mailing Address - Country:US
Mailing Address - Phone:909-982-2088
Mailing Address - Fax:909-982-2058
Practice Address - Street 1:631 N 13TH AVE
Practice Address - Street 2:A
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4946
Practice Address - Country:US
Practice Address - Phone:909-982-2088
Practice Address - Fax:909-982-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA517941Medicaid
CA00A517940Medicare ID - Type Unspecified
CAA517941Medicaid