MEDICARE: MR. GILBERTO MADRID LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS 8361	CA

General Provider Information

NPI Number	:	1003020207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GILBERTO MADRID LCSW

Provider Business Mailing Address
First Line	:	3126 WISCONSIN ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94602-4051
Country	:	US
Telephone Number	:	510-531-3894
Fax Number	:

Provider Business Practice Location Address
First Line	:	3867 HOWE ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94611-5343
Country	:	US
Telephone Number	:	510-531-3894
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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