Provider Demographics
NPI:1922116185
Name:GOMBOTZ, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GOMBOTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MALLARD LN
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-3553
Mailing Address - Country:US
Mailing Address - Phone:860-828-6873
Mailing Address - Fax:
Practice Address - Street 1:6 DAVIS RD E
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1447
Practice Address - Country:US
Practice Address - Phone:860-434-9155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT005690OtherLICENSE #