Healthcare Provider Details

I. General information

NPI: 1114556891
Provider Name (Legal Business Name): VICTORIA GAMBINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 04/05/2020
Certification Date: 04/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 W 91ST ST
NEW YORK NY
10024-1011
US

IV. Provider business mailing address

302 W 91ST ST
NEW YORK NY
10024-1011
US

V. Phone/Fax

Practice location:
  • Phone: 212-787-7120
  • Fax:
Mailing address:
  • Phone: 212-787-7120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: