Provider Demographics
NPI:1073986170
Name:CHAVARRIA, GUSTAVO ADOLFO
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ADOLFO
Last Name:CHAVARRIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 VALLECITO WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-9066
Mailing Address - Country:US
Mailing Address - Phone:415-350-0611
Mailing Address - Fax:
Practice Address - Street 1:2521 VALLECITO WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-9066
Practice Address - Country:US
Practice Address - Phone:415-350-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor