Healthcare Provider Details

I. General information

NPI: 1497747257
Provider Name (Legal Business Name): RICHARD M GOMBERG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 05/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BRACE ROAD SUITE C
CHERRY HILL NJ
08034-2624
US

IV. Provider business mailing address

1 BRACE ROAD SUITE C
CHERRY HILL NJ
08034-2624
US

V. Phone/Fax

Practice location:
  • Phone: 856-482-8900
  • Fax: 856-482-8943
Mailing address:
  • Phone: 856-482-8900
  • Fax: 856-482-8943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberOS004301L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MB4007200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: