Healthcare Provider Details

I. General information

NPI: 1891790366
Provider Name (Legal Business Name): ROGER JOHN GSTALDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S BELCHER RD
CLEARWATER FL
33764-6301
US

IV. Provider business mailing address

2031 LITTLE ROAD
NEW PORT RICHEY FL
34655-1294
US

V. Phone/Fax

Practice location:
  • Phone: 727-799-3772
  • Fax: 727-797-2957
Mailing address:
  • Phone: 727-375-0300
  • Fax: 727-375-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME 17041
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: