Provider Demographics
NPI:1053464602
Name:MIGUEL GONZALES M D PROF CORP
Entity Type:Organization
Organization Name:MIGUEL GONZALES M D PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-233-3191
Mailing Address - Street 1:9030 W SAHARA AVE # 260
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5744
Mailing Address - Country:US
Mailing Address - Phone:702-321-5293
Mailing Address - Fax:702-463-1507
Practice Address - Street 1:9030 W SAHARA AVE # 260
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5744
Practice Address - Country:US
Practice Address - Phone:702-321-5293
Practice Address - Fax:702-463-1507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV39384Medicare PIN