Provider Demographics
NPI:1770034795
Name:GONZALEZ, EDGAR O (BS)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:O
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 PALMS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-2104
Mailing Address - Country:US
Mailing Address - Phone:310-391-6352
Mailing Address - Fax:310-391-6352
Practice Address - Street 1:11350 PALMS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-2104
Practice Address - Country:US
Practice Address - Phone:310-391-7127
Practice Address - Fax:310-391-1376
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator