Provider Demographics
NPI:1942498464
Name:ALZA, GUSTAVO ALBERTO SR (MD)
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:ALBERTO
Last Name:ALZA
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5224 N FIGUEROA STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4118
Mailing Address - Country:US
Mailing Address - Phone:323-259-0456
Mailing Address - Fax:323-259-8486
Practice Address - Street 1:5224 N FIGUEROA STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4118
Practice Address - Country:US
Practice Address - Phone:323-259-0456
Practice Address - Fax:323-259-8486
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG48749207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954049700OtherBLUE CROSS/BLUE SHIELD #
CA010017308OtherRAILROAD MEDICARE #
CA954049700OtherBLUE SHIELD #
CA00G487490Medicaid
CA954049700OtherBLUE CROSS #
CA954049700OtherBLUE SHIELD #
CA954049700OtherBLUE CROSS/BLUE SHIELD #