Provider Demographics
NPI:1033484092
Name:GAUDET, JOHN GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GREGORY
Last Name:GAUDET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:GREGORY
Other - Last Name:VAN DRIEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:622 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-9876
Mailing Address - Fax:914-709-8165
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:PH5
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-9878
Practice Address - Fax:914-709-8165
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265748207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology