Healthcare Provider Details

I. General information

NPI: 1922116185
Provider Name (Legal Business Name): MARK GOMBOTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DAVIS RD E
OLD LYME CT
06371-1447
US

IV. Provider business mailing address

35 MALLARD LN
KENSINGTON CT
06037-3553
US

V. Phone/Fax

Practice location:
  • Phone: 860-434-9155
  • Fax:
Mailing address:
  • Phone: 860-828-6873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: