Healthcare Provider Details

I. General information

NPI: 1477756377
Provider Name (Legal Business Name): GUSTAVE S. DRIVAS MD. PC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RICHMOND AVE BASEMENT
STATEN ISLAND NY
10312-2025
US

IV. Provider business mailing address

3377 RICHMOND AVE BASEMENT
STATEN ISLAND NY
10312-2025
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 TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number186334
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number186334
License Number StateNY

VIII. Authorized Official

Name: DR. GUSTAVE STEPHEN DRIVAS
Title or Position: PRESIDENT
Credential: MD
Phone: 718-948-3890