Provider Demographics
NPI:1912772260
Name:GONZALEZ, GILBERTO
Entity Type:Individual
Prefix:
First Name:GILBERTO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26900 WINCHESTER CREEK AVE APT 2104
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-4104
Mailing Address - Country:US
Mailing Address - Phone:619-313-0626
Mailing Address - Fax:
Practice Address - Street 1:38338 TRANQUILA AVE
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-3224
Practice Address - Country:US
Practice Address - Phone:915-691-8904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2023-20172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver