Provider Demographics
NPI:1760685234
Name:CORONA-GONZALEZ, GONZALO (MD)
Entity Type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:CORONA-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 1:304 S LEA AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-4562
Mailing Address - Country:US
Mailing Address - Phone:575-578-4815
Mailing Address - Fax:575-578-4814
Practice Address - Street 1:304 S LEA AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-4562
Practice Address - Country:US
Practice Address - Phone:575-578-4815
Practice Address - Fax:575-578-4814
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1391208000000X
NMMD2007-0650208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11773537Medicaid
VIVI LICENSEOther1391