Provider Demographics
NPI:1467830885
Name:GOMULKA, MICHAL (MD)
Entity type:Individual
Prefix:
First Name:MICHAL
Middle Name:
Last Name:GOMULKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 ELM ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-5415
Mailing Address - Country:US
Mailing Address - Phone:732-725-1979
Mailing Address - Fax:
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6395
Practice Address - Country:US
Practice Address - Phone:732-222-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10849700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program