Healthcare Provider Details

I. General information

NPI: 1083900252
Provider Name (Legal Business Name): DAVID A GUMUCIO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2011
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19800 DETROIT RD
ROCKY RIVER OH
44116-1816
US

IV. Provider business mailing address

26908 DETROIT RD SUITE 200
WESTLAKE OH
44145-2398
US

V. Phone/Fax

Practice location:
  • Phone: 440-333-1107
  • Fax: 440-333-1064
Mailing address:
  • Phone: 440-250-8660
  • Fax: 440-250-8639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34010802
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: