=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942438932
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GUSTAVO SOSA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2009
-----------------------------------------------------
Last Update Date | 11/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 CITRUS TOWER BLVD STE 201
-----------------------------------------------------
City | CLERMONT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34711-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-708-3021
-----------------------------------------------------
Fax | 352-708-6153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1443 LONG MEADOW WAY
-----------------------------------------------------
City | WINDERMERE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34786-6086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-816-3021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 125-056300
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME113122
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------