Provider Demographics
NPI:1457858714
Name:PADRE-GOZUN, DIANE
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:PADRE-GOZUN
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 1:282 E SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-6323
Mailing Address - Country:US
Mailing Address - Phone:310-518-6861
Mailing Address - Fax:310-835-1366
Practice Address - Street 1:282 E SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-6323
Practice Address - Country:US
Practice Address - Phone:310-518-6861
Practice Address - Fax:310-835-1366
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine