Provider Demographics
NPI:1710990403
Name:GUMBOC, REYDOMINIQUE LUCERO (MD)
Entity Type:Individual
Prefix:DR
First Name:REYDOMINIQUE
Middle Name:LUCERO
Last Name:GUMBOC
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 1:5125 SKYLINE RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:TRIPLER AMC, DEPT OF ORTHOPAEDIC SURGERY
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96589
Practice Address - Country:US
Practice Address - Phone:808-433-3557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMDR4859207X00000X
CODR.0061450207XS0106X
ORMD1908822086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN