Healthcare Provider Details

I. General information

NPI: 1417960188
Provider Name (Legal Business Name): DARRELL WAYNE GONZALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE SUITE 500
LA JOLLA CA
92037-1224
US

IV. Provider business mailing address

9850 GENESEE AVE SUITE 500
LA JOLLA CA
92037-1224
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-0267
  • Fax:
Mailing address:
  • Phone: 858-657-0267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA88738
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: