Provider Demographics
NPI:1467517557
Name:JOSE MANUEL GONZALEZ-DIAZ
Entity Type:Organization
Organization Name:JOSE MANUEL GONZALEZ-DIAZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:GONZALEZ-DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-994-6177
Mailing Address - Street 1:20440 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91306-3110
Mailing Address - Country:US
Mailing Address - Phone:818-994-6177
Mailing Address - Fax:818-994-6177
Practice Address - Street 1:20440 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91306-3110
Practice Address - Country:US
Practice Address - Phone:818-994-6177
Practice Address - Fax:818-994-6177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086102Medicaid
CAA41311Medicare ID - Type Unspecified
CAGR0086102Medicaid