Healthcare Provider Details

I. General information

NPI: 1457575706
Provider Name (Legal Business Name): JORGE GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 PETALUMA AVE
SEBASTOPOL CA
95472-4215
US

IV. Provider business mailing address

501 PETALUMA AVE
SEBASTOPOL CA
95472-4215
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-8511
  • Fax: 707-829-4147
Mailing address:
  • Phone: 707-823-8511
  • Fax: 707-829-4147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberGO57888
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: