1669635785 NPI number — MICHAEL RAYMUND C GONZALES MD

Table of content: MICHAEL RAYMUND C GONZALES MD (NPI 1669635785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669635785 NPI number — MICHAEL RAYMUND C GONZALES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALES
Provider First Name:
MICHAEL RAYMUND
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669635785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 HARVARD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89502-2055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-253-0772
Provider Business Mailing Address Fax Number:
775-982-5496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10085 DOUBLE R BLVD STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89521-4832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-982-7260
Provider Business Practice Location Address Fax Number:
775-982-7268
Provider Enumeration Date:
07/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  21747 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X , with the licence number: 309848 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X , with the licence number: 0116019889 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X , with the licence number: 16309 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13817541 . This is a "CAQH NUMBER" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 6056931 . This is a "HEALTHSPRINGS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 931868 . This is a "WINDSOR HEALTH PLAN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 9971837 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P01109797 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 16309 . This is a "NV MD LIC NUMBER" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 3447931 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 8822998 . This is a "CIGNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1669635785 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09338860 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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