Provider Demographics
NPI:1942438932
Name:SOSA, GUSTAVO (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:SOSA
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 1:1443 LONG MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6086
Mailing Address - Country:US
Mailing Address - Phone:217-816-3021
Mailing Address - Fax:
Practice Address - Street 1:245 CITRUS TOWER BLVD STE 201
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1907
Practice Address - Country:US
Practice Address - Phone:352-708-3021
Practice Address - Fax:352-708-6153
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-056300207Q00000X
FLME113122207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine