Provider Demographics
NPI:1841477767
Name:BERTHA A GONZALEZ DO, INC
Entity type:Organization
Organization Name:BERTHA A GONZALEZ DO, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:323-728-1274
Mailing Address - Street 1:3106 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2217
Mailing Address - Country:US
Mailing Address - Phone:323-728-1274
Mailing Address - Fax:323-720-9954
Practice Address - Street 1:3106 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2217
Practice Address - Country:US
Practice Address - Phone:323-728-1274
Practice Address - Fax:323-720-9954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:N/A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6849302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A6849Medicare UPIN