Provider Demographics
NPI:1770773434
Name:MONDRAGON, GUSTAVO ANTONIO JR (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ANTONIO
Last Name:MONDRAGON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:480 FOURTH AVENUE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4414
Mailing Address - Country:US
Mailing Address - Phone:619-656-5252
Mailing Address - Fax:619-656-5250
Practice Address - Street 1:480 FOURTH AVENUE
Practice Address - Street 2:SUITE 500
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4414
Practice Address - Country:US
Practice Address - Phone:619-656-5252
Practice Address - Fax:619-656-5250
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2021-09-02
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Provider Licenses
StateLicense IDTaxonomies
CAA112588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine