MEDICARE: MICHELLE ANN GAMBACORTA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	009174	NY

General Provider Information

NPI Number	:	1982213906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ANN GAMBACORTA OD

Provider Business Mailing Address
First Line	:	4703 TRANSIT RD
Second Line	:
City	:	DEPEW
State	:	NY
Zip	:	14043-4861
Country	:	US
Telephone Number	:	716-656-2011
Fax Number	:

Provider Business Practice Location Address
First Line	:	4703 TRANSIT RD
Second Line	:
City	:	DEPEW
State	:	NY
Zip	:	14043-4861
Country	:	US
Telephone Number	:	716-656-2011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2020
Last Update Date	:	08/07/2020

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