Provider Demographics
NPI:1003174194
Name:MYLES E GOMBERT MD PC
Entity Type:Organization
Organization Name:MYLES E GOMBERT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MYLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-652-7647
Mailing Address - Street 1:30 WOOD RD
Mailing Address - Street 2:
Mailing Address - City:SANDS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2625
Mailing Address - Country:US
Mailing Address - Phone:516-652-7647
Mailing Address - Fax:516-944-2385
Practice Address - Street 1:30 WOOD RD
Practice Address - Street 2:
Practice Address - City:SANDS POINT
Practice Address - State:NY
Practice Address - Zip Code:11050-2625
Practice Address - Country:US
Practice Address - Phone:516-652-7647
Practice Address - Fax:516-944-2385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-26
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00607561Medicaid
NYB14864Medicare UPIN