Healthcare Provider Details

I. General information

NPI: 1962997973
Provider Name (Legal Business Name): GUSTAVO VICTORIA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 S SAN PEDRO ST
LOS ANGELES CA
90011-2023
US

IV. Provider business mailing address

14924 S CASTLEGATE AVE
EAST RANCHO DOMINGUEZ CA
90221-3024
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-3100
  • Fax: 323-233-3124
Mailing address:
  • Phone: 310-722-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55687
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA55687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: