Provider Demographics
NPI:1790760957
Name:GONZALEZ, ROBERTO ANGEL (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:ANGEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 HOOHANA ST STE A104
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2975
Mailing Address - Country:US
Mailing Address - Phone:808-866-9395
Mailing Address - Fax:
Practice Address - Street 1:360 HOOHANA ST STE A104
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2975
Practice Address - Country:US
Practice Address - Phone:808-866-9395
Practice Address - Fax:808-877-1558
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31047111N00000X
AZ7045111N00000X
HI1484111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ68808Medicare ID - Type Unspecified
AZU85025Medicare UPIN