Healthcare Provider Details

I. General information

NPI: 1932029725
Provider Name (Legal Business Name): GUADALUPE MEDICAL GROUP A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 E 10TH ST
LONG BEACH CA
90804-5508
US

IV. Provider business mailing address

4525 EAGLE ROCK BLVD
LOS ANGELES CA
90041-3214
US

V. Phone/Fax

Practice location:
  • Phone: 323-543-4535
  • Fax: 323-480-4574
Mailing address:
  • Phone: 818-846-4469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TEODULO CRUZ BONZON
Title or Position: OPERATING PROVIDER
Credential: LCSW
Phone: 818-846-4469