Provider Demographics
NPI:1205190691
Name:GUSTAVO FORTEZA MD PA
Entity Type:Organization
Organization Name:GUSTAVO FORTEZA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTEZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-992-7321
Mailing Address - Street 1:10521 SW 143RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3035
Mailing Address - Country:US
Mailing Address - Phone:305-889-4978
Mailing Address - Fax:305-504-8813
Practice Address - Street 1:10550 NW 77TH CT STE 308
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33016-2072
Practice Address - Country:US
Practice Address - Phone:305-863-2233
Practice Address - Fax:305-504-8813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85628261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE3972CMedicare Oscar/Certification