Healthcare Provider Details

I. General information

NPI: 1104853969
Provider Name (Legal Business Name): MARY L DOMBOVY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 RIDGEWAY AVE SUITE 420
ROCHESTER NY
14626-4285
US

IV. Provider business mailing address

2655 RIDGEWAY AVE SUITE 420
ROCHESTER NY
14626-4285
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-7972
  • Fax: 585-368-3119
Mailing address:
  • Phone: 585-723-7972
  • Fax: 585-368-3119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number178528
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: