1538312483 NPI number — GASTON ALBERTO CUDEMUS DESEDA M.D.

Table of content: BREANNE HENDERSON PA-C (NPI 1083213946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538312483 NPI number — GASTON ALBERTO CUDEMUS DESEDA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUDEMUS DESEDA
Provider First Name:
GASTON
Provider Middle Name:
ALBERTO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538312483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26067
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84126-0067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-624-0400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
399 9TH ST N STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34102-5820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-624-4200
Provider Business Practice Location Address Fax Number:
239-624-4241
Provider Enumeration Date:
10/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  ME143322 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LC0200X , with the licence number: ME143322 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4KXIR . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 106240800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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