Provider Demographics
NPI:1396804514
Name:GUSTAVO MARIN M.D.P.A.
Entity type:Organization
Organization Name:GUSTAVO MARIN M.D.P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NOHORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-633-8747
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10027616OtherAMERIGROUP GROUP NUMBER
TX13085OtherPARKLAND GROUP NUMBER
TXH08V4391OtherBLUE CROSS BLUE SHIELD IN
TX0086NLOtherBLUE CROSS BLUE SHIELD GR
TX8V4390OtherBLUE CROSS BLUE SHIELD IN
TX434703OtherAETNA INDIVIDUAL
TX00039ZMedicare ID - Type UnspecifiedMEDICARE GROUP
TX8V4390OtherBLUE CROSS BLUE SHIELD IN
TX8F0441Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
TXH08V4391OtherBLUE CROSS BLUE SHIELD IN