Healthcare Provider Details

I. General information

NPI: 1639983448
Provider Name (Legal Business Name): JUSTIN GEDINSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 02/03/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 HYLAN BLVD
STATEN ISLAND NY
10305-1943
US

IV. Provider business mailing address

125 COURTLAND LN
MATAWAN NJ
07747-2213
US

V. Phone/Fax

Practice location:
  • Phone: 917-397-8947
  • Fax:
Mailing address:
  • Phone: 718-440-4119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: