Healthcare Provider Details

I. General information

NPI: 1396715959
Provider Name (Legal Business Name): GEOFFREY PETER GUSTAVSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 THE GRN
NEWARK DE
19716-0009
US

IV. Provider business mailing address

282 THE GRN
NEWARK DE
19716-0009
US

V. Phone/Fax

Practice location:
  • Phone: 302-831-2227
  • Fax: 302-831-6407
Mailing address:
  • Phone: 302-831-2227
  • Fax: 302-831-6407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberC10007058
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: