Provider Demographics
NPI:1982213906
Name:GAMBACORTA, MICHELLE ANN (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:GAMBACORTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4703 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4861
Mailing Address - Country:US
Mailing Address - Phone:716-656-2011
Mailing Address - Fax:
Practice Address - Street 1:4703 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4861
Practice Address - Country:US
Practice Address - Phone:716-656-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist