Basic Information
| Provider Information | |||||||||
| NPI: | 1205254224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMEZ VILLALOBOS | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4867 W SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900275969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009548000 | ||||||||
| FaxNumber: | 8445654290 | ||||||||
| Practice Location | |||||||||
| Address1: | 4867 W SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900275969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009548000 | ||||||||
| FaxNumber: | 8445654290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2014 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A140668 | CA | N | Allopathic & Osteopathic Physicians | General Practice | 208M00000X | A140668 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | LG3232267556 | 05 | CA | MEDICAID |