Provider Demographics
NPI:1992810634
Name:ENGELHARDT, GABRIELE (MD)
Entity type:Individual
Prefix:
First Name:GABRIELE
Middle Name:
Last Name:ENGELHARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N PROSPECT AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3033
Mailing Address - Country:US
Mailing Address - Phone:310-376-8816
Mailing Address - Fax:310-374-2806
Practice Address - Street 1:520 N PROSPECT AVE STE 103
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3033
Practice Address - Country:US
Practice Address - Phone:310-376-8816
Practice Address - Fax:310-374-2806
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW475461AMedicaid
WA75461HMedicare ID - Type UnspecifiedMEDICARE PART B PPIN
CAW475461AMedicaid