Provider Demographics
NPI:1710934146
Name:CUESTA, BRAULIO MANNY (MD)
Entity Type:Individual
Prefix:
First Name:BRAULIO
Middle Name:MANNY
Last Name:CUESTA
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 1:1400 BRYAN DR
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-2158
Mailing Address - Country:US
Mailing Address - Phone:580-920-0105
Mailing Address - Fax:580-920-0893
Practice Address - Street 1:1400 BRYAN DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2158
Practice Address - Country:US
Practice Address - Phone:580-920-0105
Practice Address - Fax:580-920-0893
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13348207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100129250AMedicaid
OKC94818Medicare UPIN