Healthcare Provider Details

I. General information

NPI: 1841274909
Provider Name (Legal Business Name): RONALD GONZALES JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 N SAGINAW ST
SAINT CHARLES MI
48655-1021
US

IV. Provider business mailing address

1124 N SAGINAW ST
SAINT CHARLES MI
48655-1021
US

V. Phone/Fax

Practice location:
  • Phone: 989-865-8270
  • Fax: 989-865-8582
Mailing address:
  • Phone: 989-865-8270
  • Fax: 989-865-8582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number430107548
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: