Healthcare Provider Details

I. General information

NPI: 1215047840
Provider Name (Legal Business Name): GUSTAVO A COLBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 HOSTOS AVE MEDICAL EMPORIUM SUITE 209
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

PO BOX 901
CABO ROJO PR
00623-0901
US

V. Phone/Fax

Practice location:
  • Phone: 787-805-3232
  • Fax: 787-805-8140
Mailing address:
  • Phone: 787-805-3232
  • Fax: 787-805-8140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number11240
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: