Provider Demographics
NPI:1699771295
Name:DOMBEK-LANG, TERESA V (MD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:V
Last Name:DOMBEK-LANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:V
Other - Last Name:DOMBEKLANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 COMMERCE LN
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3739
Mailing Address - Country:US
Mailing Address - Phone:315-386-8191
Mailing Address - Fax:315-386-1410
Practice Address - Street 1:77 W. BARNEY ST.
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642
Practice Address - Country:US
Practice Address - Phone:315-287-4440
Practice Address - Fax:315-287-1858
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEL221009207Q00000X
MEMD25662207Q00000X
NY243016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
NY02392854Medicaid
NY02392854Medicaid
NY02392854Medicaid