Provider Demographics
NPI:1760844120
Name:GOMBASH, NICOLE MICHELLE (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MICHELLE
Last Name:GOMBASH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 EUCLID AVE STE RBC 838
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:216-844-4853
Mailing Address - Fax:216-844-7166
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-4853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.013784208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program