Healthcare Provider Details

I. General information

NPI: 1003867730
Provider Name (Legal Business Name): GUSTAVE STEPHEN DRIVAS M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 HYLAN BLVD
STATEN ISLAND NY
10312-5241
US

IV. Provider business mailing address

5405 HYLAN BLVD
STATEN ISLAND NY
10312-5241
US

V. Phone/Fax

Practice location:
  • Phone: 718-948-3890
  • Fax: 718-948-3961
Mailing address:
  • Phone: 718-948-3890
  • Fax: 718-948-3961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number186334
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: