Provider Demographics
NPI:1033395629
Name:MOSQUERA, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:MOSQUERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 E PLUMMER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-8047
Mailing Address - Country:US
Mailing Address - Phone:217-483-3487
Mailing Address - Fax:217-483-8150
Practice Address - Street 1:101 E PLUMMER BLVD
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-8047
Practice Address - Country:US
Practice Address - Phone:217-483-3487
Practice Address - Fax:217-483-8151
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036086050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086050Medicaid
IL036086050Medicaid