Provider Demographics
NPI:1518981281
Name:GONZALEZ, KEITH ORLANDO (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ORLANDO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 E ELVIRA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706-7124
Mailing Address - Country:US
Mailing Address - Phone:520-874-7400
Mailing Address - Fax:520-874-3425
Practice Address - Street 1:2800 E AJO WAY
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6204
Practice Address - Country:US
Practice Address - Phone:520-874-7400
Practice Address - Fax:520-874-3425
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ356102084N0400X
PAMD4628892084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034764370009Medicaid
AZP00322978OtherRR MEDICARE
AZ112240Medicaid