Basic Information
| Provider Information | |||||||||
| NPI: | 1447246988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUBERNIKOFF | ||||||||
| FirstName: | GEORGE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632046 | ||||||||
| FaxNumber: | 5166632054 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166632046 | ||||||||
| FaxNumber: | 5166632054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 152964 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00966129 | 05 | NY | MEDICAID |