Provider Demographics
NPI:1326003237
Name:CHARRIA-ORTIZ, GUSTAVO A (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:CHARRIA-ORTIZ
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 1:315 N SAN SABA STE 1135
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3255
Mailing Address - Country:US
Mailing Address - Phone:210-704-3030
Mailing Address - Fax:210-704-4257
Practice Address - Street 1:333 N SANTA ROSA
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-4841
Practice Address - Fax:210-704-4257
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT2341208000000X, 2084N0400X, 2084N0402X
NY2101292084N0400X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268264800Medicaid
FL82258Medicare ID - Type Unspecified
FL268264800Medicaid