Provider Demographics
NPI:1689667404
Name:GANCEDO, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GANCEDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 N FIGUEROA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4232
Mailing Address - Country:US
Mailing Address - Phone:323-254-5221
Mailing Address - Fax:323-254-4618
Practice Address - Street 1:4815 VALLEY BLVD STE C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90032-3300
Practice Address - Country:US
Practice Address - Phone:323-222-1134
Practice Address - Fax:323-221-4506
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 74088208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF 58522Medicare UPIN