Provider Demographics
NPI:1326328725
Name:ADALBERTO C. GONZALEZ, M.D., PROF. CORP.
Entity Type:Organization
Organization Name:ADALBERTO C. GONZALEZ, M.D., PROF. CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADALBERTO
Authorized Official - Middle Name:C
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-399-8606
Mailing Address - Street 1:3219 E CAMELBACK RD
Mailing Address - Street 2:#833
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2307
Mailing Address - Country:US
Mailing Address - Phone:602-881-5430
Mailing Address - Fax:623-399-8606
Practice Address - Street 1:5333 N 7TH ST
Practice Address - Street 2:SUITE B219
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2821
Practice Address - Country:US
Practice Address - Phone:602-881-5430
Practice Address - Fax:623-399-8606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ125212086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ12521OtherAZ LICENSE #