Provider Demographics
NPI:1073516100
Name:HUERTA, GUSTAVO (MD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:HUERTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 CRESTVIEW PARK DR
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2855
Mailing Address - Country:US
Mailing Address - Phone:615-446-5121
Mailing Address - Fax:615-446-1357
Practice Address - Street 1:704 E COLLEGE ST
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2032
Practice Address - Country:US
Practice Address - Phone:615-441-4504
Practice Address - Fax:615-446-1357
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD22062208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
020047462OtherRAILROAD MEDICARE
TN3158146OtherBLUE CROSS BLUE SHIELD TN
TN3066526Medicaid
TN3066526Medicaid
020047462OtherRAILROAD MEDICARE