Healthcare Provider Details

I. General information

NPI: 1073496501
Provider Name (Legal Business Name): IVAN ALBERTO GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: IVAN ALBERTO GONZALEZ MORALES

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21000 PLUMMER ST
CHATSWORTH CA
91311-4903
US

IV. Provider business mailing address

10612 HADDON AVE
PACOIMA CA
91331-2953
US

V. Phone/Fax

Practice location:
  • Phone: 818-882-6400
  • Fax:
Mailing address:
  • Phone: 818-224-0705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: