Basic Information
| Provider Information | |||||||||
| NPI: | 1639194848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ-AMADO | ||||||||
| FirstName: | RAFAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE #55737 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018708 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940804811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105512740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | A51030 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00A510300 | 01 | CA | MEDICAL PPIN # | OTHER |