Healthcare Provider Details

I. General information

NPI: 1205496783
Provider Name (Legal Business Name): JUSTIN GEWIRTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 07/19/2025
Certification Date: 07/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 24002
NEWARK NJ
07101-0410
US

IV. Provider business mailing address

15 KNOLLWOOD TER
RANDOLPH NJ
07869-3013
US

V. Phone/Fax

Practice location:
  • Phone: 973-273-4626
  • Fax:
Mailing address:
  • Phone: 215-260-7779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN653716
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: