Provider Demographics
NPI:1407822109
Name:TAN-GONZALES, DESIREE (MD)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:TAN-GONZALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3241 WESTERN BRANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5260
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:713 VOLVO PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1614
Practice Address - Country:US
Practice Address - Phone:757-548-0076
Practice Address - Fax:757-548-1652
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA541595397OtherCIGNA
VA010207011Medicaid
VA7172705OtherAETNA
VA10002079OtherSENTARA/OPTIMA
VA186943OtherANTHEM
VA541595397OtherMID ATLANTIC SOLUTIONS
VA541595397OtherCIGNA
008967B28Medicare PIN