Provider Demographics
NPI:1518478866
Name:DIEGO J GONZALEZ MD PC
Entity Type:Organization
Organization Name:DIEGO J GONZALEZ MD PC
Other - Org Name:NEW MEXICO PAIN ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-633-4141
Mailing Address - Street 1:8100 WYOMING BLVD NE STE M4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1963
Mailing Address - Country:US
Mailing Address - Phone:505-633-4141
Mailing Address - Fax:505-633-4144
Practice Address - Street 1:8300 CARMEL AVE NE STE 500-501
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-3147
Practice Address - Country:US
Practice Address - Phone:505-633-4141
Practice Address - Fax:505-633-4144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-13
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0165261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM61574244Medicaid