Healthcare Provider Details

I. General information

NPI: 1184679888
Provider Name (Legal Business Name): LISA MARIE GAMBINO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 ONTARIO STREET HONEOYE VALLEY FAMILY PRACTICE
HONEOYE FALLS NY
14472
US

IV. Provider business mailing address

20 BURNCOAT WAY
PITTSFORD NY
14534-2216
US

V. Phone/Fax

Practice location:
  • Phone: 585-624-2121
  • Fax:
Mailing address:
  • Phone: 585-389-1906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number151742
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: