Provider Demographics
NPI:1457575706
Name:GONZALEZ, JORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:GONZALEZ
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 1:501 PETALUMA AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4215
Mailing Address - Country:US
Mailing Address - Phone:707-823-8511
Mailing Address - Fax:707-829-4147
Practice Address - Street 1:501 PETALUMA AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4215
Practice Address - Country:US
Practice Address - Phone:707-823-8511
Practice Address - Fax:707-829-4147
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGO57888207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE13987Medicare UPIN