Provider Demographics
NPI:1619917960
Name:SANROMAN, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:SANROMAN
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 1:45 RESEARCH WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-6401
Mailing Address - Country:US
Mailing Address - Phone:631-675-2125
Mailing Address - Fax:631-675-2628
Practice Address - Street 1:5225 ROUTE 347
Practice Address - Street 2:SUITE 70
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2053
Practice Address - Country:US
Practice Address - Phone:800-645-3203
Practice Address - Fax:631-474-9169
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173068207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE62783Medicare UPIN
66F701Medicare ID - Type Unspecified