Provider Demographics
NPI:1326109091
Name:GOMBERT, MYLES EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MYLES
Middle Name:EDWARD
Last Name:GOMBERT
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 1:30 WOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:SANDS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11050
Mailing Address - Country:US
Mailing Address - Phone:516-652-7647
Mailing Address - Fax:
Practice Address - Street 1:30 WOOD ROAD
Practice Address - Street 2:
Practice Address - City:SANDS POINT
Practice Address - State:NY
Practice Address - Zip Code:11050
Practice Address - Country:US
Practice Address - Phone:516-652-7647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2010-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129224207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00607561Medicaid
B14864Medicare UPIN
NY00607561Medicaid