Provider Demographics
NPI:1336111038
Name:GEBHARD, ROBERTA E (DO)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:E
Last Name:GEBHARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-1950
Mailing Address - Country:US
Mailing Address - Phone:716-649-0887
Mailing Address - Fax:716-646-4611
Practice Address - Street 1:621 10TH ST
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1813
Practice Address - Country:US
Practice Address - Phone:716-692-3302
Practice Address - Fax:716-692-4342
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176365174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01607583Medicaid
NY01607583Medicaid
NYF90493Medicare UPIN