Provider Demographics
NPI:1730107293
Name:GANATA, JOSE ROM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ROM
Last Name:GANATA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W COLLEGE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-1650
Mailing Address - Country:US
Mailing Address - Phone:213-617-9157
Mailing Address - Fax:213-617-9158
Practice Address - Street 1:625 W COLLEGE ST STE 105
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1650
Practice Address - Country:US
Practice Address - Phone:213-617-9157
Practice Address - Fax:213-617-9158
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35837207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A358370Medicaid
CA00A358370OtherBLUE CROSS PROVIDER
CA00A358370OtherBLUE SHIELD
CA00A358370Medicare ID - Type UnspecifiedMEDICARE PROVIDER
CA00A358370OtherBLUE CROSS PROVIDER
CA1363916Medicare UPIN
CA00A358370Medicaid