MEDICARE: GONZALO CORONA-GONZALEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	1391	VI
2	208000000X	Pediatrics Physician	MD2007-0650	NM
3	207Q00000X	Family Medicine Physician	MD2007-0650	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	VI LICENSE	OTHER	VI	1391

General Provider Information

NPI Number	:	1760685234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GONZALO CORONA-GONZALEZ MD

Provider Business Mailing Address
First Line	:	304 S LEA AVE
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88203-4562
Country	:	US
Telephone Number	:	575-578-4815
Fax Number	:	575-578-4814

Provider Business Practice Location Address
First Line	:	304 S LEA AVE
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88203-4562
Country	:	US
Telephone Number	:	575-578-4815
Fax Number	:	575-578-4814

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	11/20/2018

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