Provider Demographics
NPI:1538691118
Name:PINA GOMES, CHANTAL
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:
Last Name:PINA GOMES
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-5138
Mailing Address - Fax:
Practice Address - Street 1:335 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-2517
Practice Address - Country:US
Practice Address - Phone:323-634-3850
Practice Address - Fax:323-938-9958
Is Sole Proprietor?:No
Enumeration Date:2017-04-01
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A17258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program