Provider Demographics
NPI:1306379664
Name:GONZALES, ANTONIO J IV
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:J
Last Name:GONZALES
Suffix:IV
Gender:M
Credentials:
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 26666
Mailing Address - Street 2:
Mailing Address - City:ALBUQEURQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-9770
Mailing Address - Fax:505-923-5654
Practice Address - Street 1:454 ST MICHAELS DR STE 200
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7602
Practice Address - Country:US
Practice Address - Phone:505-303-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-0150207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1306379664Medicaid