Provider Demographics
NPI:1114028057
Name:GOMBERG, JACK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:ALAN
Last Name:GOMBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BREYER CT
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1350
Mailing Address - Country:US
Mailing Address - Phone:215-886-1335
Mailing Address - Fax:
Practice Address - Street 1:8302 OLD YORK RD STE B4
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-1529
Practice Address - Country:US
Practice Address - Phone:215-628-8585
Practice Address - Fax:215-886-1335
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD015248E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAA36474OtherAMERIHEALTH
PA000839303 0003Medicaid
PA000136474OtherHIGHMARK BLUE SHIELD
PA000136474OtherHIGHMARK BLUE SHIELD
PAA36474OtherAMERIHEALTH