Provider Demographics
NPI:1942579735
Name:CUBA-GUTIERREZ, CAROLINA MILAGROS (MD)
Entity Type:Individual
Prefix:
First Name:CAROLINA
Middle Name:MILAGROS
Last Name:CUBA-GUTIERREZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLINA
Other - Middle Name:M
Other - Last Name:CUBA BUSTINZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:
Practice Address - Street 1:1010 VALLEY ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-2070
Practice Address - Country:US
Practice Address - Phone:937-641-4000
Practice Address - Fax:937-641-4500
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.130512208000000X, 2080P0006X
WI56673-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0408074Medicaid