=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386802106
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY D GASTELUM MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2008
-----------------------------------------------------
Last Update Date | 11/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 EAST 86TH STREET SUITE 604
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-249-0309
-----------------------------------------------------
Fax | 646-304-7087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 157 E 86TH ST # 461
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10028-2175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-249-0309
-----------------------------------------------------
Fax | 929-376-0009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 249353
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------