=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326386616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GUSTAVO MADRIGAL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2013
-----------------------------------------------------
Last Update Date | 09/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 W MISSION ST
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95110-1713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-535-4263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 588 BROWN RD
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94539-7011
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | ASW66184
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------