Healthcare Provider Details

I. General information

NPI: 1275965105
Provider Name (Legal Business Name): ROMMEL GONZALES MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 S ALVARADO ST
LOS ANGELES CA
90057-2904
US

IV. Provider business mailing address

508 S ALVARADO ST
LOS ANGELES CA
90057-2904
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-3600
  • Fax: 213-484-4555
Mailing address:
  • Phone: 213-483-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA122760
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA122760
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA122760
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA122760
License Number StateCA

VIII. Authorized Official

Name: ROMMEL ANGEL GONZALES
Title or Position: PRESIDENT
Credential: M.D.
Phone: 213-483-3600