Provider Demographics
NPI:1699810838
Name:GONZALEZ-WERNER, EDITH (M D)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:GONZALEZ-WERNER
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47250 WASHINGTON ST STE A
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2105
Mailing Address - Country:US
Mailing Address - Phone:760-771-9437
Mailing Address - Fax:760-564-8581
Practice Address - Street 1:47250 WASHINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2105
Practice Address - Country:US
Practice Address - Phone:760-771-9437
Practice Address - Fax:760-564-8581
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0532670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071340Medicaid
CA330705738OtherBLUE CROSS GROUP ID #
CAA53267OtherSTATE LIC #
CACJ8819OtherRAILROAD GROUP ID #
CA00A532670OtherBLUE CROSS INDV ID #
CAZZZ60889ZOtherBLUE SHIELD GROUP #
CA080184034OtherRAILROAD ID #
CA00A532670OtherBLUE SHIELD INDV ID #
CAZZZ20534ZOtherMEDICARE GROUP ID #
CA080184034OtherRAILROAD ID #
CACJ8819OtherRAILROAD GROUP ID #