Provider Demographics
NPI:1841405131
Name:MIGUEL GONZALEZ MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MIGUEL GONZALEZ MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-497-7508
Mailing Address - Street 1:227 W JANSS RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1848
Mailing Address - Country:US
Mailing Address - Phone:805-497-7508
Mailing Address - Fax:805-495-6834
Practice Address - Street 1:227 W JANSS RD
Practice Address - Street 2:SUITE 250
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1848
Practice Address - Country:US
Practice Address - Phone:805-497-7508
Practice Address - Fax:805-495-6834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG51766OtherMEDICAL LICENSE
CA00G517660Medicare ID - Type Unspecified
CAA52075Medicare UPIN