Provider Demographics
NPI:1992216675
Name:CORRE, GIMBO JOHN OBFENDA (PT)
Entity Type:Individual
Prefix:
First Name:GIMBO JOHN
Middle Name:OBFENDA
Last Name:CORRE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CLINTON RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-6340
Mailing Address - Country:US
Mailing Address - Phone:347-806-7706
Mailing Address - Fax:
Practice Address - Street 1:7708 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1927
Practice Address - Country:US
Practice Address - Phone:347-806-7706
Practice Address - Fax:631-850-5637
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038996-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist