Healthcare Provider Details

I. General information

NPI: 1720342470
Provider Name (Legal Business Name): GUSTAVO MARTIN HUAMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 W 49TH PL
HIALEAH FL
33012-3113
US

IV. Provider business mailing address

12565 NW 57TH CT
CORAL SPRINGS FL
33076-3469
US

V. Phone/Fax

Practice location:
  • Phone: 305-558-2500
  • Fax:
Mailing address:
  • Phone: 954-393-8759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9106514
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number32599
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: