Basic Information
| Provider Information | |||||||||
| NPI: | 1174554190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSTAVE | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | |||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 ROCKLAND RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514200 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 095362 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 062994 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD421678 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | MD421678 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 2080P0214X | 25MA08162100 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 208M00000X | MD421678 | PA | N | Allopathic & Osteopathic Physicians | Hospitalist | 2080P0214X | C10011083 | DE | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 101141866 | 05 | PA | MEDICAID | 0050539 | 05 | NJ | MEDICAID | 1655572 | 01 | PA | BLUE SHIELD | OTHER | 406294900 | 05 | MD | MEDICAID |