Provider Demographics
NPI:1154215077
Name:MAZA GONZALEZ, VLADIMR ADAN (N/A)
Entity type:Individual
Prefix:
First Name:VLADIMR
Middle Name:ADAN
Last Name:MAZA GONZALEZ
Suffix:
Gender:M
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10781 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:92316-2618
Mailing Address - Country:US
Mailing Address - Phone:909-233-2726
Mailing Address - Fax:909-233-2726
Practice Address - Street 1:1481 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5416
Practice Address - Country:US
Practice Address - Phone:909-361-6470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty