Provider Demographics
NPI:1902672249
Name:HURTADO, GUSTAVO JR
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:HURTADO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N D ST STE 421
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1522
Mailing Address - Country:US
Mailing Address - Phone:951-591-0682
Mailing Address - Fax:
Practice Address - Street 1:330 N D ST STE 421
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1522
Practice Address - Country:US
Practice Address - Phone:951-591-0682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker