Healthcare Provider Details

I. General information

NPI: 1528021201
Provider Name (Legal Business Name): MARY J GOMBASH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4571 WESTBOURNE RD
TOLEDO OH
43623-2015
US

IV. Provider business mailing address

4571 WESTBOURNE RD
TOLEDO OH
43623-2015
US

V. Phone/Fax

Practice location:
  • Phone: 419-841-1660
  • Fax: 419-841-4103
Mailing address:
  • Phone: 419-841-1660
  • Fax: 419-841-4103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number35047714
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: