Provider Demographics
NPI:1417967514
Name:BAMBINO, NICHOLAS GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:GEORGE
Last Name:BAMBINO
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 1:10 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518
Mailing Address - Country:US
Mailing Address - Phone:845-534-7080
Mailing Address - Fax:845-534-4171
Practice Address - Street 1:10 ELM ST
Practice Address - Street 2:
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518
Practice Address - Country:US
Practice Address - Phone:845-534-7080
Practice Address - Fax:845-534-4171
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116053207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00507979Medicaid
NY00507979Medicaid
632641Medicare ID - Type Unspecified