Provider Demographics
NPI:1538108097
Name:GONZALEZ, ALEJANDRO LAZARO
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:LAZARO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6217
Mailing Address - Country:US
Mailing Address - Phone:323-564-6464
Mailing Address - Fax:562-222-7221
Practice Address - Street 1:4225 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6217
Practice Address - Country:US
Practice Address - Phone:323-564-6464
Practice Address - Fax:562-222-7221
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6453207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX64530Medicaid
CAG02237Medicare UPIN
CA00AX64530Medicaid