Provider Demographics
NPI:1568480556
Name:GONZALEZ, CARINA FABIANA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARINA
Middle Name:FABIANA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CARINA
Other - Middle Name:F
Other - Last Name:LEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3238 IVY ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-3774
Mailing Address - Country:US
Mailing Address - Phone:209-366-3112
Mailing Address - Fax:
Practice Address - Street 1:1300 W LODI AVE STE P
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3038
Practice Address - Country:US
Practice Address - Phone:209-366-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15609207Q00000X
CAA102039207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0022878Medicare ID - Type UnspecifiedPROVIDER
PRI29189Medicare UPIN