1306876453 NPI number — EDWARD J GAYDOS DPM

Table of content: EDWARD J GAYDOS DPM (NPI 1306876453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306876453 NPI number — EDWARD J GAYDOS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAYDOS
Provider First Name:
EDWARD
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306876453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 VILLAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORWIGSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17961-9688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 LILLY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCHUYLKILL HAVEN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17972-1154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-385-1190
Provider Business Practice Location Address Fax Number:
570-385-1190
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  SC003058L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1119540001 . This is a "DMERC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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