MEDICARE: DR. GUSTAVO HUERTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	MD22062	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	020047462	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	3158146	OTHER	TN	BLUE CROSS BLUE SHIELD TN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073516100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GUSTAVO HUERTA MD

Provider Business Mailing Address
First Line	:	127 CRESTVIEW PARK DR
Second Line	:
City	:	DICKSON
State	:	TN
Zip	:	37055-2855
Country	:	US
Telephone Number	:	615-446-5121
Fax Number	:	615-446-1357

Provider Business Practice Location Address
First Line	:	704 E COLLEGE ST
Second Line	:
City	:	DICKSON
State	:	TN
Zip	:	37055-2032
Country	:	US
Telephone Number	:	615-441-4504
Fax Number	:	615-446-1357

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	02/02/2012

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