Provider Demographics
NPI:1578213823
Name:FARIA MENDEZ, GUSTAVO ENRIQUE (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ENRIQUE
Last Name:FARIA MENDEZ
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 1:7221 WILDERNESS PARK DR APT 201
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-5962
Mailing Address - Country:US
Mailing Address - Phone:281-620-6160
Mailing Address - Fax:
Practice Address - Street 1:6245 INKSTER RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-4001
Practice Address - Country:US
Practice Address - Phone:734-458-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV32932084N0400X
390200000X
MI43510498292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program