Healthcare Provider Details

I. General information

NPI: 1013916659
Provider Name (Legal Business Name): NICOLAS ANTONIO GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 E SOUTHERN AVE BLDG. H
TEMPE AZ
85282
US

IV. Provider business mailing address

2600 E SOUTHERN AVE BLDG. H
TEMPE AZ
85282
US

V. Phone/Fax

Practice location:
  • Phone: 480-699-7248
  • Fax: 480-664-1961
Mailing address:
  • Phone: 480-699-7248
  • Fax: 480-664-1961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29730
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: