Healthcare Provider Details

I. General information

NPI: 1942664859
Provider Name (Legal Business Name): MARTIN B. GONZALES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING BLVD NE
ALBUQUERQUE NM
87112
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-5300
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2020-0106
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: