Healthcare Provider Details

I. General information

NPI: 1447205067
Provider Name (Legal Business Name): GERALD WEST DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 CHESTNUT STREET
ROSELLE PARK NJ
07204
US

IV. Provider business mailing address

505 CHESTNUT ST
ROSELLE PARK NJ
07204-1918
US

V. Phone/Fax

Practice location:
  • Phone: 908-241-0200
  • Fax: 908-241-1615
Mailing address:
  • Phone: 908-241-0200
  • Fax: 908-241-1615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number22284
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number22284
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number236854
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: