Provider Demographics
NPI:1114914074
Name:CUELLO DIAZ, GUSTAVO A (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:A
Last Name:CUELLO DIAZ
Suffix:
Gender:M
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:U20 CALLE JASPER
Mailing Address - Street 2:URBANIZACION PARK GARDENS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-2139
Mailing Address - Country:US
Mailing Address - Phone:787-292-2018
Mailing Address - Fax:787-292-2018
Practice Address - Street 1:4 ERNESTO RAMOS ANTONINI
Practice Address - Street 2:BO AMELIA
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00965
Practice Address - Country:US
Practice Address - Phone:787-792-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10859208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10859OtherSTATE LICENSE