Provider Demographics
NPI:1215047840
Name:COLBERG, GUSTAVO A (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:COLBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:CABO ROJO
Mailing Address - State:PR
Mailing Address - Zip Code:00623-0901
Mailing Address - Country:US
Mailing Address - Phone:787-805-3232
Mailing Address - Fax:787-805-8140
Practice Address - Street 1:351 HOSTOS AVE
Practice Address - Street 2:MEDICAL EMPORIUM SUITE 209
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-805-3232
Practice Address - Fax:787-805-8140
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PR11240208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR89101Medicare UPIN