Provider Demographics
NPI:1699717462
Name:VILLAGOMEZ, JOSE L (MD)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:L
Last Name:VILLAGOMEZ
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 1:12099 W WASHINGTON BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5882
Mailing Address - Country:US
Mailing Address - Phone:310-398-3803
Mailing Address - Fax:310-398-5189
Practice Address - Street 1:12099 W WASHINGTON BLVD
Practice Address - Street 2:STE 400
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5882
Practice Address - Country:US
Practice Address - Phone:310-398-3803
Practice Address - Fax:310-398-5189
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61283207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A612830OtherMEDICAL
11613705OtherCAQH
CA00A612830Medicaid
11613705OtherCAQH
CA00A612830Medicaid