Healthcare Provider Details

I. General information

NPI: 1659512309
Provider Name (Legal Business Name): RENE GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4808
US

IV. Provider business mailing address

707 BROADWAY BLVD NE STE 500
ALBUQUERQUE NM
87102-2367
US

V. Phone/Fax

Practice location:
  • Phone: 505-750-2034
  • Fax:
Mailing address:
  • Phone: 505-232-9055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number86-234
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: