Healthcare Provider Details

I. General information

NPI: 1730507955
Provider Name (Legal Business Name): JAMES O GONZALES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12208 MIRANDY CT NE
ALBUQUERQUE NM
87122-1274
US

IV. Provider business mailing address

12208 MIRANDY CT NE
ALBUQUERQUE NM
87122-1274
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-4579
  • Fax:
Mailing address:
  • Phone: 505-221-6212
  • Fax: 505-221-5551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2016-0688
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: