Provider Demographics
NPI:1417928847
Name:GUTNISKY, GUSTAVO (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:GUTNISKY
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 1:1051 GAUSE BLVD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2995
Mailing Address - Country:US
Mailing Address - Phone:985-641-4152
Mailing Address - Fax:985-641-4153
Practice Address - Street 1:1051 GAUSE BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2951
Practice Address - Country:US
Practice Address - Phone:985-641-4152
Practice Address - Fax:985-641-4153
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05999R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB61058Medicare UPIN