Provider Demographics
NPI:1144204488
Name:GASCON, CUPID C (MD)
Entity Type:Individual
Prefix:
First Name:CUPID
Middle Name:C
Last Name:GASCON
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 1:3318 OAK BROOK RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-3608
Mailing Address - Country:US
Mailing Address - Phone:443-465-4740
Mailing Address - Fax:
Practice Address - Street 1:110 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2507
Practice Address - Country:US
Practice Address - Phone:315-349-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205808-1207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1144204488Medicaid
NY1144204488OtherBCBS NY EXCELLUS
MD404106200Medicaid
NY01920805Medicaid
MD568LI490Medicare ID - Type Unspecified
NY01920805Medicaid
NYJ400005288Medicare PIN