Provider Demographics
NPI:1396706628
Name:MARIN, GUSTAVO (MD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:MARIN
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 1:2380 E PARK BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5151
Mailing Address - Country:US
Mailing Address - Phone:972-633-8747
Mailing Address - Fax:972-633-8356
Practice Address - Street 1:2380 E PARK BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5151
Practice Address - Country:US
Practice Address - Phone:972-633-8747
Practice Address - Fax:972-633-8356
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE0540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00039ZMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
TX8F0441Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
TXC18783Medicare UPIN