Healthcare Provider Details

I. General information

NPI: 1770893117
Provider Name (Legal Business Name): JOSE LUIS GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 KILROY AIRPORT WAY STE 100
LONG BEACH CA
90806-6818
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 231-669-6453
  • Fax:
Mailing address:
  • Phone: 323-442-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberA114052
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA114052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: