1477756377 NPI number — GUSTAVE S. DRIVAS MD. PC.

Table of content: (NPI 1477756377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477756377 NPI number — GUSTAVE S. DRIVAS MD. PC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUSTAVE S. DRIVAS MD. PC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1477756377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3377 RICHMOND AVE
Provider Second Line Business Mailing Address:
BASEMENT
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10312-2025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-948-3890
Provider Business Mailing Address Fax Number:
718-948-3961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3377 RICHMOND AVE
Provider Second Line Business Practice Location Address:
BASEMENT
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10312-2025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-948-3890
Provider Business Practice Location Address Fax Number:
718-948-3961
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DRIVAS
Authorized Official First Name:
GUSTAVE
Authorized Official Middle Name:
STEPHEN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-948-3890

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  186334 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 186334 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01522467 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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