Provider Demographics
NPI:1356978845
Name:GORBONOSOV, MICHELLE SABRINA (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SABRINA
Last Name:GORBONOSOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:834 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-955-1329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD484176207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine