Provider Demographics
NPI:1154840304
Name:FAUSTINO M. GONZALEZ, MD PC
Entity Type:Organization
Organization Name:FAUSTINO M. GONZALEZ, MD PC
Other - Org Name:FAUSTINO M. GONZALEZ, MD PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:FAUSTINO
Authorized Official - Middle Name:M
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-529-6422
Mailing Address - Street 1:3309 N 85TH PLACE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251
Mailing Address - Country:US
Mailing Address - Phone:602-529-6422
Mailing Address - Fax:602-529-6433
Practice Address - Street 1:11811 N. TATUM BLVD
Practice Address - Street 2:SUITE 3031
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028
Practice Address - Country:US
Practice Address - Phone:602-529-6422
Practice Address - Fax:602-529-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23659207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1043238801Medicaid