Provider Demographics
NPI:1477756377
Name:GUSTAVE S. DRIVAS MD. PC.
Entity Type:Organization
Organization Name:GUSTAVE S. DRIVAS MD. PC.
Other - Org Name:HUGUENOT LASER ARTS AND HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVE
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:DRIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-948-3890
Mailing Address - Street 1:3377 RICHMOND AVE
Mailing Address - Street 2:BASEMENT
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2025
Mailing Address - Country:US
Mailing Address - Phone:718-948-3890
Mailing Address - Fax:718-948-3961
Practice Address - Street 1:3377 RICHMOND AVE
Practice Address - Street 2:BASEMENT
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2025
Practice Address - Country:US
Practice Address - Phone:718-948-3890
Practice Address - Fax:718-948-3961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186334207LP2900X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01522467Medicaid
NY01522467Medicaid
NYF86028Medicare UPIN