Healthcare Provider Details

I. General information

NPI: 1467185686
Provider Name (Legal Business Name): OSVALDO GUTIERREZ CASTANEDA SR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 08/30/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 MORENA BLVD
SAN DIEGO CA
92110-3815
US

IV. Provider business mailing address

1250 MORENA BLVD
SAN DIEGO CA
92110-3815
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8715
  • Fax:
Mailing address:
  • Phone: 619-692-8750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: