Provider Demographics
NPI:1134197791
Name:GONZALES, CARLOS R (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:R
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 1:2701 E ELVIRA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706-7124
Mailing Address - Country:US
Mailing Address - Phone:520-281-1550
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:2701 E ELVIRA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-7124
Practice Address - Country:US
Practice Address - Phone:520-281-1550
Practice Address - Fax:520-281-1112
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00376509OtherRR MEDICARE
AZ249715Medicaid
AZFQ31809CMedicare ID - Type UnspecifiedMEDICARE#
AZ249715Medicaid
AZZ110760Medicare PIN
AZD43981Medicare UPIN