Provider Demographics
NPI:1427575943
Name:DE MORAES, CARLOS GUSTAVO VASCONCELOS (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS GUSTAVO
Middle Name:VASCONCELOS
Last Name:DE MORAES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:635 W 165TH ST # 69
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3724
Mailing Address - Country:US
Mailing Address - Phone:347-834-7986
Mailing Address - Fax:
Practice Address - Street 1:635 W 165TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-9535
Practice Address - Fax:212-305-5523
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290203207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05070719Medicaid