Provider Demographics
NPI:1023199429
Name:GUSTILO, ROSE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:GUSTILO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2518 DARDA ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-1588
Mailing Address - Country:US
Mailing Address - Phone:702-617-3597
Mailing Address - Fax:
Practice Address - Street 1:2518 DARDA ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89044-1588
Practice Address - Country:US
Practice Address - Phone:702-617-3597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035835E2084P0800X
VA01010508852084P0800X
MDD237772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ136841Medicaid