Provider Demographics
NPI:1194836759
Name:SOSTRE, GILBERTO (MD)
Entity type:Individual
Prefix:
First Name:GILBERTO
Middle Name:
Last Name:SOSTRE
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 1:1499 WALTON WAY, SUITE 1400
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2602
Mailing Address - Country:US
Mailing Address - Phone:706-828-8401
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH STREET
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-9729
Practice Address - Fax:706-721-8507
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0236842085R0202X, 2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0000892482AMedicaid
SCG23684Medicaid
GA30BDJSZMedicare ID - Type Unspecified
GA0000892482AMedicaid