Provider Demographics
NPI:1952644304
Name:BAMBERG, ERIC JOHN (LMT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
Last Name:BAMBERG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1901
Mailing Address - Country:US
Mailing Address - Phone:716-551-0970
Mailing Address - Fax:716-931-5658
Practice Address - Street 1:167 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1901
Practice Address - Country:US
Practice Address - Phone:716-551-0970
Practice Address - Fax:716-931-5658
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026863225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist