Healthcare Provider Details

I. General information

NPI: 1194836759
Provider Name (Legal Business Name): GILBERTO SOSTRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH STREET DEPARTMENT OF RADIOLOGY
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1499 WALTON WAY, SUITE 1400 PROVIDER ENROLLMENT
AUGUSTA GA
30901-2602
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-9729
  • Fax: 706-721-8507
Mailing address:
  • Phone: 706-828-8401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number023684
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number023684
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: