Provider Demographics
NPI:1821289927
Name:MEJIA, GUSTAVO (DC)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:MEJIA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8722
Mailing Address - Country:US
Mailing Address - Phone:631-968-0586
Mailing Address - Fax:631-968-6720
Practice Address - Street 1:8 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8722
Practice Address - Country:US
Practice Address - Phone:631-968-0586
Practice Address - Fax:631-968-6720
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX003936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX003936OtherLICENSE