Provider Demographics
NPI:1841303872
Name:GUASTAVINO, THOMAS D (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:GUASTAVINO
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:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-0510
Mailing Address - Country:US
Mailing Address - Phone:570-622-5672
Mailing Address - Fax:570-622-6099
Practice Address - Street 1:700 SCHUYLKILL MANOR RD
Practice Address - Street 2:SUITE 1
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3849
Practice Address - Country:US
Practice Address - Phone:570-622-5672
Practice Address - Fax:570-622-6099
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040617E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA519559Medicare PIN
C63178Medicare UPIN