Healthcare Provider Details

I. General information

NPI: 1760685234
Provider Name (Legal Business Name): GONZALO CORONA-GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S LEA AVE
ROSWELL NM
88203-4562
US

IV. Provider business mailing address

304 S LEA AVE
ROSWELL NM
88203-4562
US

V. Phone/Fax

Practice location:
  • Phone: 575-578-4815
  • Fax: 575-578-4814
Mailing address:
  • Phone: 575-578-4815
  • Fax: 575-578-4814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1391
License Number StateVI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2007-0650
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2007-0650
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: