Healthcare Provider Details

I. General information

NPI: 1346358827
Provider Name (Legal Business Name): GUSTAVO CALLEROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BELLEFONTAINE ST SUITE 401
PASADENA CA
91105-3132
US

IV. Provider business mailing address

1217 W WHITTIER BLVD
MONTEBELLO CA
90640-4642
US

V. Phone/Fax

Practice location:
  • Phone: 626-793-1931
  • Fax: 626-793-0161
Mailing address:
  • Phone: 323-728-6070
  • Fax: 323-728-2912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA74210
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: