Basic Information
| Provider Information | |||||||||
| NPI: | 1932191533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOSA | ||||||||
| FirstName: | GUSTAVO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2750 GATEWAY OAKS DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958333668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557710335 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2825 CAPITOL AVE, FL 1 | ||||||||
| Address2: | STE 1S118 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168870104 | ||||||||
| FaxNumber: | 9168870112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | G61005 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G610050 | 05 | CA | MEDICAID |