Healthcare Provider Details

I. General information

NPI: 1316879596
Provider Name (Legal Business Name): DONFRED GERTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4471 41ST AVE STE 1014
COLUMBUS NE
68601-9405
US

IV. Provider business mailing address

4471 41ST AVE STE 1014
COLUMBUS NE
68601-9405
US

V. Phone/Fax

Practice location:
  • Phone: 203-996-5456
  • Fax: 877-283-6658
Mailing address:
  • Phone: 203-996-5456
  • Fax: 877-283-6658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberG635-160-62-464-0
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: