Provider Demographics
NPI:1578611737
Name:CARDENAS, GUSTAVO A (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:A
Last Name:CARDENAS
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 1:74 E WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1314
Mailing Address - Country:US
Mailing Address - Phone:631-654-1749
Mailing Address - Fax:631-654-1790
Practice Address - Street 1:74 E WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1314
Practice Address - Country:US
Practice Address - Phone:631-654-1749
Practice Address - Fax:631-654-1790
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1000015665OtherAFFINITY
NY0082356OtherGHI
NY11-2432871OtherTAX ID
NY226752POtherHIP
NY431247OtherUNITED HEALTHCARE
NY2375OtherVYTRA
NY20502OtherAETNA
NYP1233307OtherOXFORD FREEDOM PLAN
NY2375OtherVYTRA
NY226752POtherHIP