1063875508 NPI number — JESUS FABIOLA GASTELUM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063875508 NPI number — JESUS FABIOLA GASTELUM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JESUS FABIOLA GASTELUM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063875508
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4364 BONITA RD
Provider Second Line Business Mailing Address:
#233
Provider Business Mailing Address City Name:
BONITA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91902-1421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CALLE 4A #2013
Provider Second Line Business Practice Location Address:
ZONA CENTRO
Provider Business Practice Location Address City Name:
TIJUANA
Provider Business Practice Location Address State Name:
BAJA CALIFORNIA
Provider Business Practice Location Address Postal Code:
22000
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
011526643295224
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GASTELUM GASTELUM
Authorized Official First Name:
JESUS
Authorized Official Middle Name:
FABIOLA
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
011526643295224

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  1787539 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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