Provider Demographics
NPI:1275965105
Name:ROMMEL GONZALES MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ROMMEL GONZALES MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROMMEL
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-483-3600
Mailing Address - Street 1:508 S ALVARADO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-2904
Mailing Address - Country:US
Mailing Address - Phone:213-483-3600
Mailing Address - Fax:
Practice Address - Street 1:508 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2904
Practice Address - Country:US
Practice Address - Phone:213-483-3600
Practice Address - Fax:213-484-4555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122760207VG0400X, 207VX0000X, 208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid