Provider Demographics
NPI:1932191533
Name:SOSA, GUSTAVO (MD)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:
Last Name:SOSA
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 1:2750 GATEWAY OAKS DR STE 150
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-3668
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:
Practice Address - Street 1:2825 CAPITOL AVE, FL 1
Practice Address - Street 2:STE 1S118
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816
Practice Address - Country:US
Practice Address - Phone:916-887-0104
Practice Address - Fax:916-887-0112
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG610052080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G610050Medicaid
E56216Medicare UPIN
CA2220065752Medicare ID - Type Unspecified