Provider Demographics
NPI:1659512309
Name:GONZALEZ, RENE (MD)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
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 1:707 BROADWAY BLVD NE STE 500
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2367
Mailing Address - Country:US
Mailing Address - Phone:505-232-9055
Mailing Address - Fax:
Practice Address - Street 1:4201 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4808
Practice Address - Country:US
Practice Address - Phone:505-750-2034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-2342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM22605304Medicaid