Provider Demographics
NPI:1053615799
Name:GOMPRECHT, ELLEN REGINA (MD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:REGINA
Last Name:GOMPRECHT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MILDLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708
Mailing Address - Country:US
Mailing Address - Phone:914-584-1578
Mailing Address - Fax:
Practice Address - Street 1:125 MILDLAND AVENUE
Practice Address - Street 2:
Practice Address - City:BRONXVILLE
Practice Address - State:NY
Practice Address - Zip Code:10708
Practice Address - Country:US
Practice Address - Phone:914-584-1578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161113-1207R00000X
CAA 44828207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine