Healthcare Provider Details

I. General information

NPI: 1700446895
Provider Name (Legal Business Name): GIDON COUSSIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 OLD SHORT HILLS RD
LIVINGSTON NJ
07039-5672
US

IV. Provider business mailing address

66 BROWNING RD
SHORT HILLS NJ
07078-1142
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-5000
  • Fax:
Mailing address:
  • Phone: 917-478-3951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00525000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MP00525000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: