Provider Demographics
NPI:1568656791
Name:EASTSIDE FAMILY MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:EASTSIDE FAMILY MEDICAL ASSOCIATES, INC.
Other - Org Name:EASTSIDE FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:J
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-261-4706
Mailing Address - Street 1:321 S MEDNIK AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-1839
Mailing Address - Country:US
Mailing Address - Phone:323-261-4706
Mailing Address - Fax:323-262-6874
Practice Address - Street 1:321 S MEDNIK AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1839
Practice Address - Country:US
Practice Address - Phone:323-261-4706
Practice Address - Fax:323-261-4124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74790261Q00000X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G747901Medicaid
CA00G747901Medicaid
CAF89575Medicare UPIN