Provider Demographics
NPI:1912248030
Name:OCTAVIO GONZALEZ MD
Entity Type:Organization
Organization Name:OCTAVIO GONZALEZ MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OCTAVIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:424-265-8678
Mailing Address - Street 1:PO BOX 3062
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3062
Mailing Address - Country:US
Mailing Address - Phone:424-265-8678
Mailing Address - Fax:888-847-2037
Practice Address - Street 1:29409 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-1137
Practice Address - Country:US
Practice Address - Phone:424-265-8678
Practice Address - Fax:888-847-2037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69063207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HD219AMedicare PIN