Provider Demographics
NPI:1649268426
Name:ROBUSTO, GERALD RICHARD (DO)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:RICHARD
Last Name:ROBUSTO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:RICH
Other - Middle Name:
Other - Last Name:ROBUSTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3919 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3087
Mailing Address - Country:US
Mailing Address - Phone:220-558-0405
Mailing Address - Fax:330-558-0421
Practice Address - Street 1:3919 CENTER RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3087
Practice Address - Country:US
Practice Address - Phone:220-558-0405
Practice Address - Fax:330-558-0421
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007490R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2430524Medicaid
OHH87312Medicare UPIN
OH2430524Medicaid