Provider Demographics
NPI:1720289481
Name:GONZALEZ-TRUONG, ANGELINA MARISSA (MD)
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:MARISSA
Last Name:GONZALEZ-TRUONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7734 N 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7816
Mailing Address - Country:US
Mailing Address - Phone:623-931-2444
Mailing Address - Fax:
Practice Address - Street 1:7734 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7816
Practice Address - Country:US
Practice Address - Phone:623-931-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN11026208000000X
FLME108093208000000X
AZ46847208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002747400Medicaid
GA003100082AMedicaid
AZ786657OtherAHCCCS