Provider Demographics
NPI:1972587467
Name:COLMENARES, GUSTAVO A (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:A
Last Name:COLMENARES
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:PO BOX 602478
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2478
Mailing Address - Country:US
Mailing Address - Phone:704-863-9600
Mailing Address - Fax:704-863-9601
Practice Address - Street 1:10545 BLAIR RD
Practice Address - Street 2:SUITE 1200
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-2800
Practice Address - Country:US
Practice Address - Phone:704-863-9600
Practice Address - Fax:704-863-9601
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0056015207Q00000X, 207P00000X
SC31295207Q00000X
NC2008-01450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910201Medicaid
SC312959Medicaid
SCAA35257772Medicare PIN
NC2022808EMedicare PIN
NC2022808DMedicare PIN
NC2022808SMedicare PIN
NCNC2526BMedicare PIN
MNH72348Medicare UPIN
NC2022808AMedicare UPIN
NC5910201Medicaid
NC2022808Medicare PIN
NCNC2526AMedicare PIN
NC2022808BMedicare PIN
NC2022808JMedicare PIN
NCNC2526CMedicare UPIN
NC2022808HMedicare PIN
MN080011784Medicare PIN
NC2022808KMedicare PIN
NC2022808PMedicare PIN
NC2022808CMedicare PIN