Provider Demographics
NPI:1770569196
Name:FORTEZA, GUSTAVO (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:FORTEZA
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 1:10521 SW 143RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-3035
Mailing Address - Country:US
Mailing Address - Phone:305-889-4978
Mailing Address - Fax:
Practice Address - Street 1:10550 NW 77TH CT STE 308
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33016-2072
Practice Address - Country:US
Practice Address - Phone:305-863-2233
Practice Address - Fax:305-504-8813
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0085628208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258912500Medicaid
FL29018OtherBLUE CROSS/ BLUE SHIELD
FLE3972ZMedicare PIN
FL258912500Medicaid