Provider Demographics
NPI:1720348568
Name:GONZALES, LELA THERESE (MD)
Entity Type:Individual
Prefix:
First Name:LELA
Middle Name:THERESE
Last Name:GONZALES
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:STE BG05
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-2392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-28
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD173266207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500693980Medicaid
ORP01547776OtherRR MEDICARE (PH&S)-PMG
ORR182778Medicare PIN
ORR182788Medicare PIN
ORR188925Medicare PIN
OR500693980Medicaid
ORR182781Medicare PIN