MEDICARE: GUADALUPE MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1053902734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUADALUPE MEDICAL GROUP

Provider Business Mailing Address
First Line	:	4525 EAGLE ROCK BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3214
Country	:	US
Telephone Number	:	818-846-4469
Fax Number	:

Provider Business Practice Location Address
First Line	:	1711 W TEMPLE ST STE 5658
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-7337
Country	:	US
Telephone Number	:	323-543-4535
Fax Number	:

Authorized Official
Title or Position	:	OPERATING PROVIDER
Name	:	MR. TEODULO CRUZ BONZON
Credential	:	LCSW
Telephone Number	:	818-846-4469

Provider Enumeration Date	:	01/27/2021
Last Update Date	:	01/27/2021

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Directions to “GUADALUPE MEDICAL GROUP ” Practice Location

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