Provider Demographics
NPI:1477627495
Name:GONZALES, MARTIN
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:VICKIE
Other - Middle Name:
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3924 W MARICOPA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85009-5410
Mailing Address - Country:US
Mailing Address - Phone:602-353-9352
Mailing Address - Fax:
Practice Address - Street 1:3924 W MARICOPA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-5410
Practice Address - Country:US
Practice Address - Phone:602-353-9352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8896385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ910035OtherAHCCCS ID NUMBER