Healthcare Provider Details

I. General information

NPI: 1851582324
Provider Name (Legal Business Name): GUSTAVO CASILLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10418 VALLEY BLVD # B
EL MONTE CA
91731-3600
US

IV. Provider business mailing address

10418 VALLEY BLVD # B
EL MONTE CA
91731-3600
US

V. Phone/Fax

Practice location:
  • Phone: 626-453-8466
  • Fax: 626-453-8465
Mailing address:
  • Phone: 626-453-8466
  • Fax: 626-453-8465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA102761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: