Provider Demographics
NPI:1073496501
Name:GONZALEZ, IVAN ALBERTO
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:ALBERTO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:IVAN
Other - Middle Name:ALBERTO
Other - Last Name:GONZALEZ MORALES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10612 HADDON AVE
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-2953
Mailing Address - Country:US
Mailing Address - Phone:818-224-0705
Mailing Address - Fax:
Practice Address - Street 1:21000 PLUMMER ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-4903
Practice Address - Country:US
Practice Address - Phone:818-882-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-30
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program