Provider Demographics
NPI:1164493888
Name:GIMBEL, EVANGELINE AUSTRIA (MD)
Entity type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:AUSTRIA
Last Name:GIMBEL
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 1:7950 CHERRY AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4022
Mailing Address - Country:US
Mailing Address - Phone:909-434-1657
Mailing Address - Fax:909-231-6231
Practice Address - Street 1:7950 CHERRY AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-4022
Practice Address - Country:US
Practice Address - Phone:909-434-1657
Practice Address - Fax:909-231-6231
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA050667208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164493888Medicaid