=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801064647
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALFONSO M. BAEZ, M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2008
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14127 S VERMONT AVE
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90247-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-532-1650
-----------------------------------------------------
Fax | 310-532-2036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14127 S VERMONT AVE
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90247-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-532-1650
-----------------------------------------------------
Fax | 310-532-2036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | DR. ALFONSO M. BAEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-532-1650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | A35887
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------