Healthcare Provider Details

I. General information

NPI: 1528138336
Provider Name (Legal Business Name): LEONARDO ALFONSO GARDUNO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 S PACIFIC AVE
GLENDALE CA
91204-1441
US

IV. Provider business mailing address

519 EAST BROADWAY
GLENDALE CA
91205
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-1500
  • Fax: 818-241-3500
Mailing address:
  • Phone: 818-409-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA33758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: