Healthcare Provider Details

I. General information

NPI: 1972587467
Provider Name (Legal Business Name): GUSTAVO A COLMENARES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10545 BLAIR RD SUITE 1200
MINT HILL NC
28227-2800
US

IV. Provider business mailing address

PO BOX 602478
CHARLOTTE NC
28260-2478
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-9600
  • Fax: 704-863-9601
Mailing address:
  • Phone: 704-863-9600
  • Fax: 704-863-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0056015
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31295
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2008-01450
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDR.0056015
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: