Healthcare Provider Details

I. General information

NPI: 1124116942
Provider Name (Legal Business Name): CHARLES LAGAYA GELLIDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 CLIFTON AVE STE 203
CLIFTON NJ
07013-3523
US

IV. Provider business mailing address

1005 CLIFTON AVE STE 203
CLIFTON NJ
07013-3523
US

V. Phone/Fax

Practice location:
  • Phone: 888-605-3975
  • Fax: 888-605-3975
Mailing address:
  • Phone: 888-605-3975
  • Fax: 888-605-3975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMA069939
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberMA69939
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number230269
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: