Healthcare Provider Details

I. General information

NPI: 1770806200
Provider Name (Legal Business Name): GAYTEN CARROLL BOUZANE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 LITTLETON RD
PARSIPPANY NJ
07054-2801
US

IV. Provider business mailing address

45 BRIARCLIFF RD
MOUNTAIN LAKES NJ
07046-1304
US

V. Phone/Fax

Practice location:
  • Phone: 973-334-0014
  • Fax: 973-334-0155
Mailing address:
  • Phone: 973-303-8950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25 MA08647300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: