Provider Demographics
NPI:1073601852
Name:GONZALEZ, JOSE IGNACIO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:IGNACIO
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:PO BOX 64447
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85728
Mailing Address - Country:US
Mailing Address - Phone:520-458-1208
Mailing Address - Fax:520-458-1675
Practice Address - Street 1:157 N CORONADO DR
Practice Address - Street 2:STE A
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6360
Practice Address - Country:US
Practice Address - Phone:520-458-1208
Practice Address - Fax:520-458-1675
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21227207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ12587408Medicaid
AZ12587408Medicaid
67178Medicare ID - Type Unspecified