Healthcare Provider Details

I. General information

NPI: 1073575973
Provider Name (Legal Business Name): CEDAR CREST ENT ASSOCIATES P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 S CEDAR CREST BLVD SUITE 100
ALLENTOWN PA
18103-6205
US

IV. Provider business mailing address

1251 S CEDAR CREST BLVD SUITE 100
ALLENTOWN PA
18103-6205
US

V. Phone/Fax

Practice location:
  • Phone: 610-770-9797
  • Fax: 610-770-9521
Mailing address:
  • Phone: 610-770-9797
  • Fax: 610-770-9521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMD022099E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberMD022099E
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberMD022099E
License Number StatePA

VIII. Authorized Official

Name: DR. THEODORE H GAYLOR
Title or Position: M.D./PRESIDENT
Credential: M.D.
Phone: 610-770-9797