Provider Demographics
NPI:1689159519
Name:GONZALES, MIKE C JR (NMD)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:C
Last Name:GONZALES
Suffix:JR
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8532 E BELLEVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85257-4176
Mailing Address - Country:US
Mailing Address - Phone:210-823-9390
Mailing Address - Fax:
Practice Address - Street 1:1257 W WARNER RD STE A4
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2786
Practice Address - Country:US
Practice Address - Phone:602-935-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18-1750175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath