Provider Demographics
NPI:1215087515
Name:COSUE, LAMBERTO GUTIERREZ III (MD)
Entity type:Individual
Prefix:
First Name:LAMBERTO
Middle Name:GUTIERREZ
Last Name:COSUE
Suffix:III
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:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:RULEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38771-0369
Mailing Address - Country:US
Mailing Address - Phone:662-756-4024
Mailing Address - Fax:662-756-4114
Practice Address - Street 1:840 N OAK AVE
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-3227
Practice Address - Country:US
Practice Address - Phone:662-756-4024
Practice Address - Fax:662-756-4114
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14620207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000116018Medicaid
MSBC 4719158OtherDEA LICENSE
MSG18732Medicare UPIN
MS11206340Medicare PIN