Provider Demographics
NPI:1336955954
Name:SUSTACHE PRIMARY CARE LLC
Entity type:Organization
Organization Name:SUSTACHE PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GILBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSTACHE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:832-763-0833
Mailing Address - Street 1:65 BOSTON POST RD W STE 100
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1872
Mailing Address - Country:US
Mailing Address - Phone:508-422-4844
Mailing Address - Fax:351-202-1665
Practice Address - Street 1:65 BOSTON POST RD W STE 100
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1872
Practice Address - Country:US
Practice Address - Phone:508-422-4844
Practice Address - Fax:351-202-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty