Provider Demographics
NPI:1316025224
Name:GONZALES, ROBERT M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
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:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1771
Practice Address - Street 1:5515 PIONEER ST
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-3375
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1649
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60743586207Q00000X
CAA61461207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2095183Medicaid
00A614610Medicare ID - Type Unspecified
CA00A614610Medicaid