Basic Information
| Provider Information | |||||||||
| NPI: | 1952992463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ MANCERA | ||||||||
| FirstName: | MIGUEL | ||||||||
| MiddleName: | SANTIAGO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 WILSHIRE BLVD APT 328 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900364693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7867573384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8700 BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900481804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104233277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2021 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | PTL5076 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.