Provider Demographics
NPI:1588639207
Name:GONZALEZ, CELERINA (MD)
Entity Type:Individual
Prefix:
First Name:CELERINA
Middle Name:
Last Name:GONZALEZ
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 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5375
Mailing Address - Fax:763-587-4205
Practice Address - Street 1:1833 2ND AVE S - MAIL STOP 39300A
Practice Address - Street 2:RIVERWAY CLINIC - ANOKA
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-2432
Practice Address - Country:US
Practice Address - Phone:763-587-4400
Practice Address - Fax:763-587-4205
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN738590100Medicaid
B53144Medicare UPIN
MN738590100Medicaid