Provider Demographics
NPI:1033480496
Name:CEPERO, GUSTAVO
Entity Type:Individual
Prefix:MRS
First Name:GUSTAVO
Middle Name:
Last Name:CEPERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17240 S TAMIAMI TRL
Mailing Address - Street 2:SUITE#6
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4574
Mailing Address - Country:US
Mailing Address - Phone:239-603-6836
Mailing Address - Fax:786-752-3280
Practice Address - Street 1:8477 CORAL DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33967-2641
Practice Address - Country:US
Practice Address - Phone:239-603-6836
Practice Address - Fax:786-752-3280
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA66643225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist