Provider Demographics
NPI:1225064298
Name:HEUDEBERT, GUSTAVO R (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:R
Last Name:HEUDEBERT
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 1:2055 E SOUTH BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-2002
Mailing Address - Country:US
Mailing Address - Phone:334-284-5211
Mailing Address - Fax:334-284-9020
Practice Address - Street 1:2055 E SOUTH BLVD STE 202
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2002
Practice Address - Country:US
Practice Address - Phone:334-284-5211
Practice Address - Fax:334-284-9020
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19069207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000025535OtherBLUE CROSS
AL110123736OtherRAILROAD MEDICARE
AL20604OtherHEALTHSPRING OF ALABAMA
AL000045092Medicaid
AL000045092OtherBLUE CROSS
AL000025535Medicaid
ALF07687OtherVIVA
ALF07687OtherVIVA
AL000045092Medicare ID - Type Unspecified