Provider Demographics
NPI:1366671380
Name:MAEGAWA, GUSTAVO HENRIQUE BOFF (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:HENRIQUE BOFF
Last Name:MAEGAWA
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:PO BOX 100296
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0296
Mailing Address - Country:US
Mailing Address - Phone:352-627-9350
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:BOX 100296
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0296
Practice Address - Country:US
Practice Address - Phone:352-627-9350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-12
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD69890207SG0201X, 207SG0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015796200Medicaid
MD419002500Medicaid
MD169553Y64Medicare PIN
MD419002500Medicaid