Provider Demographics
NPI:1104853969
Name:DOMBOVY, MARY L (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:DOMBOVY
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 1:2655 RIDGEWAY AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4285
Mailing Address - Country:US
Mailing Address - Phone:585-723-7972
Mailing Address - Fax:585-368-3119
Practice Address - Street 1:2655 RIDGEWAY AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4285
Practice Address - Country:US
Practice Address - Phone:585-723-7972
Practice Address - Fax:585-368-3119
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178528208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
1785286OtherWORKERS COMP
NY01674533Medicaid
B52470Medicare UPIN
NY01674533Medicaid
NYBB6559-GRP:70008AMedicare PIN