Healthcare Provider Details

I. General information

NPI: 1457337255
Provider Name (Legal Business Name): FRED GONZALES NINONUEVO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL CAMP PENDLETON BLDG H100 ATTN: CODE 094
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

585 LANDS END WAY UNIT 233
OCEANSIDE CA
92054-7287
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1555
  • Fax: 760-725-1350
Mailing address:
  • Phone: 760-231-8679
  • Fax: 760-231-8679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP 1987
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: