Healthcare Provider Details

I. General information

NPI: 1104990852
Provider Name (Legal Business Name): GERARD GUY PROSPER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

427 WHITEWOOD RD
ENGLEWOOD NJ
07631-1944
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5000
  • Fax:
Mailing address:
  • Phone: 201-541-9147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number168898
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: