Healthcare Provider Details

I. General information

NPI: 1003984162
Provider Name (Legal Business Name): NERISSA GUBALLA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E 76TH ST
NEW YORK NY
10021
US

IV. Provider business mailing address

408 E 76TH ST
NEW YORK NY
10021
US

V. Phone/Fax

Practice location:
  • Phone: 212-249-0900
  • Fax: 212-249-5277
Mailing address:
  • Phone: 212-249-0900
  • Fax: 212-249-5277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number220682
License Number StateNY

VIII. Authorized Official

Name: DR. NERISSA SYLVIA GUBALLA
Title or Position: PRESIDENT
Credential: MD
Phone: 212-249-0900