Provider Demographics
NPI:1043208218
Name:GONZALEZ, DAVID MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MANUEL
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 1:901 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-9621
Mailing Address - Country:US
Mailing Address - Phone:307-885-5824
Mailing Address - Fax:307-885-5982
Practice Address - Street 1:110 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-9409
Practice Address - Country:US
Practice Address - Phone:307-885-5824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9795207RC0000X
CO26748207RC0000X
WY4237A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY21403310Medicaid
ID807643600Medicaid
CO91084Medicare ID - Type Unspecified