MEDICARE: GUSTAVO FORTEZA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	ME0085628	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	29018	OTHER	FL	BLUE CROSS/ BLUE SHIELD

General Provider Information

NPI Number	:	1770569196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUSTAVO FORTEZA M.D.

Provider Business Mailing Address
First Line	:	10521 SW 143RD AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-3035
Country	:	US
Telephone Number	:	305-889-4978
Fax Number	:

Provider Business Practice Location Address
First Line	:	10550 NW 77TH CT STE 308
Second Line	:
City	:	HIALEAH GARDENS
State	:	FL
Zip	:	33016-2072
Country	:	US
Telephone Number	:	305-863-2233
Fax Number	:	305-504-8813

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	04/29/2022

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