Healthcare Provider Details

I. General information

NPI: 1134064504
Provider Name (Legal Business Name): DIEGO GONZALEZ MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 JEFFERSON LANE NE SUITE C
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

8100 WYOMING BLVD NE SUITE M4 #308
ALBUQUERQUE NM
87113
US

V. Phone/Fax

Practice location:
  • Phone: 505-633-4141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIEGO J GONZALEZ
Title or Position: DOCTOR
Credential: MD
Phone: 505-250-8337