Healthcare Provider Details

I. General information

NPI: 1245977214
Provider Name (Legal Business Name): GUSTAVO GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 06/11/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E 77TH ST
NEW YORK NY
10075-1850
US

IV. Provider business mailing address

100 E 77TH ST
NEW YORK NY
10075-1850
US

V. Phone/Fax

Practice location:
  • Phone: 212-434-2158
  • Fax:
Mailing address:
  • Phone: 212-434-2158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number337687
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: