Provider Demographics
NPI:1568434652
Name:MACHICADO, GUSTAVO A (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:A
Last Name:MACHICADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18350 ROSCOE BLVD STE 604
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-4190
Mailing Address - Country:US
Mailing Address - Phone:818-885-6261
Mailing Address - Fax:818-885-8256
Practice Address - Street 1:18350 ROSCOE BLVD STE 604
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4190
Practice Address - Country:US
Practice Address - Phone:818-885-6261
Practice Address - Fax:818-885-8256
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG308630207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G308630Medicaid
G30863Medicare ID - Type Unspecified
CA00G308630Medicaid
CAHH369ZMedicare PIN