Provider Demographics
NPI:1639265747
Name:GUMABON, ELIZARDO DOMINGO (NURSE)
Entity Type:Individual
Prefix:MR
First Name:ELIZARDO
Middle Name:DOMINGO
Last Name:GUMABON
Suffix:
Gender:M
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 WHITE OAK CT
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-5332
Mailing Address - Country:US
Mailing Address - Phone:732-473-1569
Mailing Address - Fax:732-473-9974
Practice Address - Street 1:1098 WHITE OAK CT
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-5332
Practice Address - Country:US
Practice Address - Phone:732-473-1569
Practice Address - Fax:732-473-9974
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NE01041700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse