Provider Demographics
NPI:1093808941
Name:GILSANZ, VICENTE (MD, PHD)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:
Last Name:GILSANZ
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7901
Mailing Address - Country:US
Mailing Address - Phone:323-361-2337
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS# 81
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2411
Practice Address - Fax:323-666-4655
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA338002085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A338000 F85OtherCAL OPTIMA
CA00A338000Medicaid
CA00A338000 F85OtherCAL OPTIMA
CAWA33800AMedicare ID - Type Unspecified