Provider Demographics
NPI:1932257201
Name:GONZALEZ, ROBERTO A
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:A
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 1:274 E ROWLAND ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3185
Mailing Address - Country:US
Mailing Address - Phone:626-966-5422
Mailing Address - Fax:626-966-5722
Practice Address - Street 1:274 E ROWLAND ST
Practice Address - Street 2:SUITE G
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3185
Practice Address - Country:US
Practice Address - Phone:626-966-5422
Practice Address - Fax:626-966-5722
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTN01048F343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01048FMedicaid