Provider Demographics
NPI:1528021201
Name:GOMBASH, MARY J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:J
Last Name:GOMBASH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4571 WESTBOURNE RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-2015
Mailing Address - Country:US
Mailing Address - Phone:419-841-1660
Mailing Address - Fax:419-841-4103
Practice Address - Street 1:4571 WESTBOURNE RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-2015
Practice Address - Country:US
Practice Address - Phone:419-841-1660
Practice Address - Fax:419-841-4103
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350477142084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0688707Medicaid
A17156Medicare UPIN
GO0607163Medicare ID - Type Unspecified