Provider Demographics
NPI:1548306954
Name:ROSALES, GUSTAVO A (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:ROSALES
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 1:1860 HOWE AVE
Mailing Address - Street 2:SUITE 440
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1073
Mailing Address - Country:US
Mailing Address - Phone:916-569-8484
Mailing Address - Fax:916-550-5003
Practice Address - Street 1:3701 J ST
Practice Address - Street 2:SUITE 201
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5562
Practice Address - Country:US
Practice Address - Phone:916-454-2345
Practice Address - Fax:916-550-5003
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA041475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A414750Medicaid
CA00A414750Medicaid
CA00A414750Medicaid