Provider Demographics
NPI:1538332234
Name:GUSTAVO A. ROSALES, MD, INC.
Entity type:Organization
Organization Name:GUSTAVO A. ROSALES, MD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-428-0656
Mailing Address - Street 1:5385 FRANKLIN BLVD STE K
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-4717
Mailing Address - Country:US
Mailing Address - Phone:916-428-0656
Mailing Address - Fax:916-428-3763
Practice Address - Street 1:7275 E SOUTHGATE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2628
Practice Address - Country:US
Practice Address - Phone:916-428-0656
Practice Address - Fax:916-428-3763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA414750208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A414750Medicaid
CA00A414750Medicaid
CA00A414750Medicare PIN