Provider Demographics
NPI:1891149316
Name:GONZALES, MIGUEL ROBERTO (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ROBERTO
Last Name:GONZALES
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 1:6036 N 19TH AVE STE 506
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2143
Mailing Address - Country:US
Mailing Address - Phone:602-246-5525
Mailing Address - Fax:
Practice Address - Street 1:6036 N 19TH AVE STE 506
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2143
Practice Address - Country:US
Practice Address - Phone:602-246-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMMD2019-0254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program