Basic Information
Provider Information | |||||||||
NPI: | 1700089596 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GAMBACORTA | ||||||||
FirstName: | PETER | ||||||||
MiddleName: | LOUIS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3925 SHERIDAN DR | ||||||||
Address2: | STE 100 | ||||||||
City: | AMHERST | ||||||||
State: | NY | ||||||||
PostalCode: | 142261738 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7162506492 | ||||||||
FaxNumber: | 7162506522 | ||||||||
Practice Location | |||||||||
Address1: | 8750 TRANSIT RD | ||||||||
Address2: | SUITE 105 | ||||||||
City: | EAST AMHERST | ||||||||
State: | NY | ||||||||
PostalCode: | 140512610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166361470 | ||||||||
FaxNumber: | 7166361423 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2007 | ||||||||
LastUpdateDate: | 09/13/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 256227 | NY | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 1700089596 | 01 | NY | NPI | OTHER | 256227 | 01 | NY | LICENSE | OTHER |