Provider Demographics
NPI:1336297910
Name:GUBERNICK, MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:GUBERNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARTIN
Other - Middle Name:
Other - Last Name:GUBERNICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:131 E 65TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-7006
Mailing Address - Country:US
Mailing Address - Phone:212-288-1422
Mailing Address - Fax:212-879-2606
Practice Address - Street 1:131 E 65TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-7006
Practice Address - Country:US
Practice Address - Phone:212-288-1422
Practice Address - Fax:212-879-2606
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157816174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY84D281Medicare ID - Type Unspecified
NYA64483Medicare UPIN