1417141912 NPI number — DANIELA GAMBOA SEJAS MD

Table of content: DANIELA GAMBOA SEJAS MD (NPI 1417141912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417141912 NPI number — DANIELA GAMBOA SEJAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAMBOA SEJAS
Provider First Name:
DANIELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAMBOA
Provider Other First Name:
DANIELA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417141912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6828 DELEON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75039-3437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-725-7950
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1173 W JOHN CARPENTER FREEWAY
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-947-6020
Provider Business Practice Location Address Fax Number:
469-947-6021
Provider Enumeration Date:
08/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  N8188 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 63127881 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01217236 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 217849301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200302930 A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8DS368 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 217849303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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