Provider Demographics
NPI:1902178486
Name:GABRIEL GUSTIN MD PC
Entity Type:Organization
Organization Name:GABRIEL GUSTIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-250-5893
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-0417
Mailing Address - Country:US
Mailing Address - Phone:917-250-5893
Mailing Address - Fax:718-478-6050
Practice Address - Street 1:4036 82ND ST STE 2
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1312
Practice Address - Country:US
Practice Address - Phone:718-478-0338
Practice Address - Fax:718-478-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213265207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04463636Medicaid