Provider Demographics
NPI:1013916659
Name:GONZALEZ, NICOLAS ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:ANTONIO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 E SOUTHERN AVE
Mailing Address - Street 2:BLDG. H
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282
Mailing Address - Country:US
Mailing Address - Phone:480-699-7248
Mailing Address - Fax:480-664-1961
Practice Address - Street 1:2600 E SOUTHERN AVE
Practice Address - Street 2:BLDG. H
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-699-7248
Practice Address - Fax:480-664-1961
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ29730208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3Z0260OtherHEALTHNET
AZ610560Medicaid
H58965Medicare UPIN
AZH58965Medicare UPIN