Provider Demographics
NPI:1861664765
Name:GONZALEZ, CARLOS (PT)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16702 VALLEY VIEW
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638
Mailing Address - Country:US
Mailing Address - Phone:714-361-5360
Mailing Address - Fax:714-635-5428
Practice Address - Street 1:754 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-2544
Practice Address - Country:US
Practice Address - Phone:909-460-4155
Practice Address - Fax:909-988-4414
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT335000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACZ965ZOtherMEDICARE