Provider Demographics
NPI:1265444129
Name:GOMEZ GARCIA, MARCO A (MD)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:A
Last Name:GOMEZ GARCIA
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 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-240-4031
Mailing Address - Fax:818-240-4035
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-240-4031
Practice Address - Fax:818-240-4035
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A842630Medicaid
CAH96723Medicare UPIN
CAWA84263AMedicare PIN