Healthcare Provider Details

I. General information

NPI: 1578660346
Provider Name (Legal Business Name): RENE GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11333 SEPULVEDA BLVD
MISSION HILLS CA
91345-1116
US

IV. Provider business mailing address

PO BOX 9602
MISSION HILLS CA
91346-9602
US

V. Phone/Fax

Practice location:
  • Phone: 818-837-5730
  • Fax: 818-837-5783
Mailing address:
  • Phone: 818-837-5691
  • Fax: 818-792-4793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA96013
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: