Provider Demographics
NPI:1033422571
Name:GONZALEZ, ERIC GABRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:GABRIEL
Last Name:GONZALEZ
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 1:1533 E WILLETTA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2935
Mailing Address - Country:US
Mailing Address - Phone:602-569-3999
Mailing Address - Fax:602-569-3887
Practice Address - Street 1:616 E SOUTHERN AVE
Practice Address - Street 2:#103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204
Practice Address - Country:US
Practice Address - Phone:602-569-3999
Practice Address - Fax:602-569-3887
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18622208000000X
AZ51791208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ120323Medicaid