Healthcare Provider Details

I. General information

NPI: 1700089596
Provider Name (Legal Business Name): PETER LOUIS GAMBACORTA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8750 TRANSIT RD SUITE 105
EAST AMHERST NY
14051-2610
US

IV. Provider business mailing address

3925 SHERIDAN DR STE 100
AMHERST NY
14226-1738
US

V. Phone/Fax

Practice location:
  • Phone: 716-636-1470
  • Fax: 716-636-1423
Mailing address:
  • Phone: 716-250-6492
  • Fax: 716-250-6522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number256227
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: