Provider Demographics
NPI:1205927415
Name:GONZALEZ-DIAZ, JOSE MANUEL (MD)
Entity type:Individual
Prefix:
First Name:JOSE MANUEL
Middle Name:
Last Name:GONZALEZ-DIAZ
Suffix:
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 1:13500 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331
Mailing Address - Country:US
Mailing Address - Phone:818-896-2999
Mailing Address - Fax:818-896-8449
Practice Address - Street 1:13500 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331
Practice Address - Country:US
Practice Address - Phone:818-896-2999
Practice Address - Fax:818-896-8449
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41311208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0086101Medicaid
CAA41311Medicare ID - Type Unspecified
D34091Medicare UPIN