Provider Demographics
NPI:1851454490
Name:GUSSOW, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GUSSOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W ELM AVE
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-5125
Mailing Address - Country:US
Mailing Address - Phone:717-632-4900
Mailing Address - Fax:717-632-4313
Practice Address - Street 1:33 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-3502
Practice Address - Country:US
Practice Address - Phone:717-632-4900
Practice Address - Fax:717-637-2611
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067026L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009361860001Medicaid
PAGU026702Medicare PIN
PA1009361860001Medicaid