Provider Demographics
NPI:1184685893
Name:GONZALES, RICHARD (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:GONZALES
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 1:8585 KNOTT AVE
Mailing Address - Street 2:#101
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620
Mailing Address - Country:US
Mailing Address - Phone:714-821-8588
Mailing Address - Fax:714-821-4482
Practice Address - Street 1:8585 KNOTT AVE
Practice Address - Street 2:#101
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620
Practice Address - Country:US
Practice Address - Phone:714-821-8588
Practice Address - Fax:714-821-4482
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A721930Medicaid
H76988Medicare UPIN
CA00A721930Medicaid