Healthcare Provider Details

I. General information

NPI: 1316884760
Provider Name (Legal Business Name): IRENEE NIYONGOMBWA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 MAIN ST
JOHNSON CITY NY
13790-1810
US

IV. Provider business mailing address

507 MAIN ST
JOHNSON CITY NY
13790-1810
US

V. Phone/Fax

Practice location:
  • Phone: 607-763-6075
  • Fax: 607-763-5234
Mailing address:
  • Phone: 607-763-6075
  • Fax: 607-763-5234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: