Provider Demographics
NPI:1174605612
Name:GUSTAVO A ALZA MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:GUSTAVO A ALZA MD A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:ALZA
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:323-259-0456
Mailing Address - Street 1:5224 N FIGUEROA STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4118
Mailing Address - Country:US
Mailing Address - Phone:323-259-0456
Mailing Address - Fax:323-259-8486
Practice Address - Street 1:5224 N FIGUEROA STREET
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-4118
Practice Address - Country:US
Practice Address - Phone:323-259-0456
Practice Address - Fax:323-259-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48749207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADB6615OtherRAILROAD MEDICARE #
CA00G487490Medicaid
CA=========OtherBLUE CROSS/BLUE SHIELD #
CADB6615OtherRAILROAD MEDICARE #
CA00G487490Medicaid
CA=========OtherBLUE SHIELD #
CAA51160Medicare UPIN