Provider Demographics
NPI:1720342470
Name:HUAMAN, GUSTAVO MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:MARTIN
Last Name:HUAMAN
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 1:12565 NW 57TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3469
Mailing Address - Country:US
Mailing Address - Phone:954-393-8759
Mailing Address - Fax:
Practice Address - Street 1:1475 W 49TH PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3113
Practice Address - Country:US
Practice Address - Phone:305-558-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106514363AS0400X
FL32599208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical