Provider Demographics
NPI:1235124496
Name:MTOMBOTI, GLORIA (MD)
Entity Type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:
Last Name:MTOMBOTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:346 CONEY ISLAND AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-1802
Mailing Address - Country:US
Mailing Address - Phone:917-443-3633
Mailing Address - Fax:
Practice Address - Street 1:50 E 40TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2911
Practice Address - Country:US
Practice Address - Phone:718-771-8000
Practice Address - Fax:347-750-1639
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224918-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02329711Medicaid
NY5105D1Medicare ID - Type Unspecified