Provider Demographics
NPI:1194106369
Name:COSTA FERNANDES FILHO, GILSON MAURO (MD)
Entity type:Individual
Prefix:DR
First Name:GILSON
Middle Name:MAURO
Last Name:COSTA FERNANDES FILHO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4100
Mailing Address - Country:US
Mailing Address - Phone:617-414-5405
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVE STE 3500
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2905
Practice Address - Country:US
Practice Address - Phone:617-638-8776
Practice Address - Fax:617-414-8772
Is Sole Proprietor?:No
Enumeration Date:2015-06-14
Last Update Date:2025-01-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA1014564207R00000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110199208AMedicaid