Provider Demographics
NPI:1205898509
Name:SUSTACHE, GILBERTO JR (MD)
Entity type:Individual
Prefix:
First Name:GILBERTO
Middle Name:
Last Name:SUSTACHE
Suffix:JR
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 1:378 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-2675
Mailing Address - Country:US
Mailing Address - Phone:508-595-2513
Mailing Address - Fax:508-595-2021
Practice Address - Street 1:378 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-2675
Practice Address - Country:US
Practice Address - Phone:508-595-2513
Practice Address - Fax:508-595-2021
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8210207Q00000X
MA295121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI23372Medicare UPIN