Provider Demographics
NPI:1407833510
Name:GONZALES, MILA G (MD)
Entity Type:Individual
Prefix:
First Name:MILA
Middle Name:G
Last Name: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:PO BOX 74881
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0964
Mailing Address - Country:US
Mailing Address - Phone:440-816-6428
Mailing Address - Fax:440-816-6438
Practice Address - Street 1:4065 CENTER RD STE 216
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-5325
Practice Address - Country:US
Practice Address - Phone:330-558-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-038475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000201811OtherANTHEM
OH000400732OtherAETNA
OH080137208OtherRAILROAD MEDICARE PIN
OHCG4360OtherRAILROAD MEDICARE GROUP
OH341652755006OtherTRICARE
OH84133OtherQUAL CHOICE
OH0100568OtherUNITED HEALTH CARE
OH0367508Medicaid
OH341652755006OtherTRICARE
OHCG4360OtherRAILROAD MEDICARE GROUP
OHOA9305451Medicare ID - Type UnspecifiedGROUP