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General NPI Number Information
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NPI Number | 1841442738
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Entity Type | Individual
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Provider Name | LUIS OMAR ONTIVEROS MD
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Gender | Male
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Dates
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Enumeration Date | 10/22/2008
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Last Update Date | 01/01/2020
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Provider Practice Location Address
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Address Line | 972 GOODRICH BLVD
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City | COMMERCE
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State | CA
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Zip | 90022-4114
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Country | US
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Telephone | 323-853-6060
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Fax | 213-995-9894
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Provider Business Mailing Address
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Address Line | 972 GOODRICH BLVD
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City | COMMERCE
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State | CA
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Zip | 90022-4114
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Country | US
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Telephone | 323-853-6060
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Fax | 213-995-9894
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 13301
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A101545
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License Number State | CA
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