Basic Information
| Provider Information | |||||||||
| NPI: | 1770585432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLOMBEK | ||||||||
| FirstName: | SERGIO | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 ROUTE 66 FL 3 | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077532645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328070877 | ||||||||
| FaxNumber: | 2017511680 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 PROSPECT AVE RM 218 | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519965362 | ||||||||
| FaxNumber: | 5519963232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 204505 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | 25MA10751300 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01689183 | 05 | NY | MEDICAID | PENDING | 05 | NJ | MEDICAID |