Basic Information
| Provider Information | |||||||||
| NPI: | 1942273958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOMALASKI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217520944 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 HICKORY ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217520944 | ||||||||
| FaxNumber: | 3214347590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME71006 | FL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VX0201X | ME71006 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000433300 | 05 | FL | MEDICAID |