Provider Demographics
NPI:1780613562
Name:GUSTIN, GABRIEL (MD)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:GUSTIN
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 1:245 NORTH MAIN STREET STE 417
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-0417
Mailing Address - Country:US
Mailing Address - Phone:718-478-0338
Mailing Address - Fax:718-478-6050
Practice Address - Street 1:3769 80TH ST FL 2
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6830
Practice Address - Country:US
Practice Address - Phone:718-478-0338
Practice Address - Fax:718-673-6107
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213265174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01947557Medicaid
NYG33418Medicare UPIN
NY05343Medicare ID - Type Unspecified