Healthcare Provider Details

I. General information

NPI: 1487688214
Provider Name (Legal Business Name): GREGORY GERSTEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 MAIN ST S UNION SQUARE
SOUTHBURY CT
06488-4240
US

IV. Provider business mailing address

385 MAIN ST S UNION SQUARE BLDG #1 C O NVRA IMAGING NETWORK
SOUTHBURY CT
06488-4240
US

V. Phone/Fax

Practice location:
  • Phone: 203-264-7999
  • Fax: 203-264-7477
Mailing address:
  • Phone: 203-264-7999
  • Fax: 203-264-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number036955
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number036955
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036955
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: