Provider Demographics
NPI:1790186112
Name:MINDFUL PEDIATRIC GASTROENTEROLOGY, INC
Entity Type:Organization
Organization Name:MINDFUL PEDIATRIC GASTROENTEROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GILBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:BULTRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-800-4059
Mailing Address - Street 1:65 N MADISON AVE
Mailing Address - Street 2:SUITE 709
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2035
Mailing Address - Country:US
Mailing Address - Phone:626-800-4059
Mailing Address - Fax:626-800-3974
Practice Address - Street 1:65 N MADISON AVE
Practice Address - Street 2:SUITE 709
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2035
Practice Address - Country:US
Practice Address - Phone:626-800-4059
Practice Address - Fax:626-800-3974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1068432080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty