Provider Demographics
NPI:1376863712
Name:GONZALEZ, MARILOU MARCELO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILOU
Middle Name:MARCELO
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 388
Mailing Address - Street 2:427 N. 12TH STREET
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851
Mailing Address - Country:US
Mailing Address - Phone:208-686-1931
Mailing Address - Fax:208-686-0213
Practice Address - Street 1:MAIRMN HEALTH
Practice Address - Street 2:427 N. 12TH STREET
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:208-686-5133
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-13052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN