Provider Demographics
NPI:1982856290
Name:MICHELLE GONZALES MD PC
Entity Type:Organization
Organization Name:MICHELLE GONZALES MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-639-1204
Mailing Address - Street 1:3601 VISTA WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4559
Mailing Address - Country:US
Mailing Address - Phone:760-639-1204
Mailing Address - Fax:760-630-1252
Practice Address - Street 1:3601 VISTA WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4559
Practice Address - Country:US
Practice Address - Phone:760-639-1204
Practice Address - Fax:760-630-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-17
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABL573AMedicare PIN