Provider Demographics
NPI:1497747257
Name:GOMBERG, RICHARD M (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:GOMBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BRACE ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2624
Mailing Address - Country:US
Mailing Address - Phone:856-482-8900
Mailing Address - Fax:856-482-8943
Practice Address - Street 1:1 BRACE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2624
Practice Address - Country:US
Practice Address - Phone:856-482-8900
Practice Address - Fax:856-482-8943
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004301L207RC0000X
NJ25MB4007200207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2356007Medicaid
NJG096707Medicare ID - Type Unspecified
NJ2356007Medicaid