Basic Information
Provider Information | |||||||||
NPI: | 1588056758 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GABRIEL | ||||||||
FirstName: | GENEVIEVE | ||||||||
MiddleName: | KHONGHUN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D, | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KHONGHUN | ||||||||
OtherFirstName: | GENEVIEVE | ||||||||
OtherMiddleName: | CO | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 829642 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191829642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8664706626 | ||||||||
FaxNumber: | 4135990470 | ||||||||
Practice Location | |||||||||
Address1: | 89 FRENCH ST FL 2 | ||||||||
Address2: |   | ||||||||
City: | NEW BRUNSWICK | ||||||||
State: | NJ | ||||||||
PostalCode: | 089011935 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322357875 | ||||||||
FaxNumber: | 7322356620 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/25/2015 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | E-10639 | AR | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2084N0400X | E-10639 | AR | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 25MA10835600 | NJ | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.