Provider Demographics
NPI:1417229535
Name:FOMBU, ALBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:
Last Name:FOMBU
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 1:283 BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT GRETNA
Mailing Address - State:PA
Mailing Address - Zip Code:17064-6085
Mailing Address - Country:US
Mailing Address - Phone:717-673-2417
Mailing Address - Fax:
Practice Address - Street 1:169 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1724
Practice Address - Country:US
Practice Address - Phone:717-733-0311
Practice Address - Fax:717-738-6735
Is Sole Proprietor?:No
Enumeration Date:2012-02-05
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4542522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103067285Medicaid