Healthcare Provider Details

I. General information

NPI: 1831459015
Provider Name (Legal Business Name): HENRY J GONZALEZ M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 SAN BERNARDINO RD
UPLAND CA
91786-4920
US

IV. Provider business mailing address

PO BOX 148
CLAREMONT CA
91711-0148
US

V. Phone/Fax

Practice location:
  • Phone: 909-985-2811
  • Fax:
Mailing address:
  • Phone: 909-985-2112
  • Fax: 909-985-3411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG56342
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG56342
License Number StateCA

VIII. Authorized Official

Name: HENRY J GONZALEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-985-2112