Provider Demographics
NPI:1467545764
Name:RINCON, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:RINCON
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 1:7350 INDUSTRIAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5318
Mailing Address - Country:US
Mailing Address - Phone:216-732-9480
Mailing Address - Fax:
Practice Address - Street 1:7350 INDUSTRIAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5318
Practice Address - Country:US
Practice Address - Phone:216-732-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034669R207RC0000X
OH35.034669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0450711Medicaid
OHA74032Medicare UPIN
OHRI7348281Medicare PIN