Provider Demographics
NPI:1669635785
Name:GONZALES, MICHAEL RAYMUND C (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL RAYMUND
Middle Name:C
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:518-253-0772
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:10085 DOUBLE R BLVD STE 310
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-4832
Practice Address - Country:US
Practice Address - Phone:775-982-7260
Practice Address - Fax:775-982-7268
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21747207RE0101X
LA309848207RE0101X
VA0116019889390200000X
NV16309207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV13817541OtherCAQH NUMBER
MS6056931OtherHEALTHSPRINGS
MS931868OtherWINDSOR HEALTH PLAN
MS9971837OtherAETNA
MSP01109797OtherRAILROAD MEDICARE
NV16309OtherNV MD LIC NUMBER
MS3447931OtherUNITED HEALTHCARE
MS8822998OtherCIGNA
NV1669635785Medicaid
MS09338860Medicaid