Basic Information
| Provider Information | |||||||||
| NPI: | 1528270063 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GUSTAVO A ROSALES MD, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ROSALES MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5385 FRANKLIN BLVD SUITE K | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164280656 | ||||||||
| FaxNumber: | 9164283763 | ||||||||
| Practice Location | |||||||||
| Address1: | 5385 FRANKLIN BLVD SUITE K | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164280656 | ||||||||
| FaxNumber: | 9164283763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 07/02/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSALES | ||||||||
| AuthorizedOfficialFirstName: | GUSTAVO | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9164280656 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A414750 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 00A414750 | 05 | CA | MEDICAID |