Provider Demographics
NPI:1528078433
Name:GOMBOSI, RUSSELL LEWIS (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LEWIS
Last Name:GOMBOSI
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 1:3155 LYCOMING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1032
Mailing Address - Country:US
Mailing Address - Phone:570-651-9263
Mailing Address - Fax:570-651-9773
Practice Address - Street 1:3155 LYCOMING CREEK RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1032
Practice Address - Country:US
Practice Address - Phone:570-651-9263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043621L207RS0012X, 208000000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4626556OtherAETNA
PA1866448OtherUNITEDHEALTHCARE
PA191328OtherHIGHMARK BLUE SHIELD
PA1866448OtherUNITEDHEALTHCARE
E68743Medicare UPIN
PA1866448OtherUNITEDHEALTHCARE
PA191328Medicare PIN
PAP00107725Medicare PIN
PA14669OtherGEISINGER HEALTH PLAN
PA191328OtherHIGHMARK BLUE SHIELD
PA0070910070003Medicaid
E68743Medicare UPIN