Provider Demographics
NPI:1245405125
Name:STRONG, GUSTI LICKFIELD (DO)
Entity Type:Individual
Prefix:
First Name:GUSTI
Middle Name:LICKFIELD
Last Name:STRONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:GUSTI
Other - Middle Name:NUESSLE
Other - Last Name:LICKFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:25 MASTERS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-383-6867
Mailing Address - Fax:
Practice Address - Street 1:1500 SPRING GARDEN ST SUITE 800
Practice Address - Street 2:BRAVOHEALTH
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130
Practice Address - Country:US
Practice Address - Phone:215-606-6925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MBO5791100207Q00000X
PAOSO11024L207Q00000X
MDH0066773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine