Provider Demographics
NPI:1447946470
Name:MIRABAL, GUSTAVO ALBERTO (MEDICAL STUDENT MS4)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ALBERTO
Last Name:MIRABAL
Suffix:
Gender:M
Credentials:MEDICAL STUDENT MS4
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE PRINCIPE 641
Mailing Address - Street 2:EXT. EL COMANDANTE
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00982
Mailing Address - Country:US
Mailing Address - Phone:939-249-7814
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-2407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty