Provider Demographics
NPI:1043738339
Name:GONZALES, MARIA SUSANA ESPINO
Entity Type:Individual
Prefix:
First Name:MARIA SUSANA
Middle Name:ESPINO
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44014 KIRKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-3631
Mailing Address - Country:US
Mailing Address - Phone:626-497-2773
Mailing Address - Fax:
Practice Address - Street 1:101 E BEVERLY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4315
Practice Address - Country:US
Practice Address - Phone:323-722-5163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFAC00083950335V00000X
293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
No335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier