Provider Demographics
NPI:1528138336
Name:GARDUNO, LEONARDO ALFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:LEONARDO
Middle Name:ALFONSO
Last Name:GARDUNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 EAST BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:818-409-3020
Mailing Address - Fax:
Practice Address - Street 1:437 S PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1441
Practice Address - Country:US
Practice Address - Phone:818-241-1500
Practice Address - Fax:818-241-3500
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA33758Medicaid
CAA33758Medicaid
CAWA33758SMedicare ID - Type Unspecified