Healthcare Provider Details

I. General information

NPI: 1962062430
Provider Name (Legal Business Name): MATTHEW SAMUEL GAMBINO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 N BROADWAY STE A
PENNSVILLE NJ
08070-1754
US

IV. Provider business mailing address

48 N BROADWAY STE A
PENNSVILLE NJ
08070-1754
US

V. Phone/Fax

Practice location:
  • Phone: 856-678-4800
  • Fax: 856-678-3630
Mailing address:
  • Phone: 856-678-4800
  • Fax: 856-678-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00693100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003556
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: