Healthcare Provider Details

I. General information

NPI: 1790835411
Provider Name (Legal Business Name): PRABHAKAR R GUMBULA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5467 UPPER MOUNTAIN ROAD
LOCKPORT NY
14094-1895
US

IV. Provider business mailing address

5467 UPPER MOUNTAIN ROAD SUITE 200
LOCKPORT NY
14094-1895
US

V. Phone/Fax

Practice location:
  • Phone: 716-439-7400
  • Fax: 716-439-7521
Mailing address:
  • Phone: 716-439-7400
  • Fax: 716-439-7521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2312811
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: