Healthcare Provider Details

I. General information

NPI: 1124345673
Provider Name (Legal Business Name): MICHAEL GUMUKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BROAD ST
GLENS FALLS NY
12801-4349
US

IV. Provider business mailing address

9 CAREY RD
QUEENSBURY NY
12804-7880
US

V. Phone/Fax

Practice location:
  • Phone: 518-792-2223
  • Fax: 518-792-8231
Mailing address:
  • Phone: 518-761-0300
  • Fax: 518-824-2388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number269376
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: