Provider Demographics
NPI:1942226410
Name:DEPETRIS, GUSTAVO RAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:RAUL
Last Name:DEPETRIS
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 1:2322 30TH AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3255
Mailing Address - Country:US
Mailing Address - Phone:718-956-7988
Mailing Address - Fax:718-267-1990
Practice Address - Street 1:2322 30TH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-3255
Practice Address - Country:US
Practice Address - Phone:718-956-7988
Practice Address - Fax:718-267-1990
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196792207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY196792OtherLIC ID
NY01630524Medicaid
NY196792OtherLIC ID
NY01630524Medicaid