Provider Demographics
NPI:1477621431
Name:MARCO GOMEZ-GARCIA, M.D. INC
Entity Type:Organization
Organization Name:MARCO GOMEZ-GARCIA, M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOMEZ-GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-240-4031
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-240-4031
Mailing Address - Fax:818-240-4035
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-240-4031
Practice Address - Fax:818-240-4035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17203Medicare PIN
CAH96723Medicare UPIN