Provider Demographics
NPI:1083802573
Name:J. MANUEL GONZALEZ-DIAZ M.D.
Entity Type:Organization
Organization Name:J. MANUEL GONZALEZ-DIAZ M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:HALVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-994-6177
Mailing Address - Street 1:13500 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-3028
Mailing Address - Country:US
Mailing Address - Phone:818-896-2999
Mailing Address - Fax:818-896-8449
Practice Address - Street 1:13500 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-3028
Practice Address - Country:US
Practice Address - Phone:818-896-2999
Practice Address - Fax:818-896-8449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALAB62080F291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086101Medicaid