Provider Demographics
NPI:1386531069
Name:DE LOS SANTOS GERVACIO, ERWIN JESUS
Entity type:Individual
Prefix:
First Name:ERWIN
Middle Name:JESUS
Last Name:DE LOS SANTOS GERVACIO
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 1:5233 E BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-2020
Mailing Address - Country:US
Mailing Address - Phone:323-499-3650
Mailing Address - Fax:
Practice Address - Street 1:225 N MARIPOSA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4509
Practice Address - Country:US
Practice Address - Phone:213-736-5441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical