Healthcare Provider Details

I. General information

NPI: 1306379664
Provider Name (Legal Business Name): MR. ANTONIO J GONZALES IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 ST MICHAELS DR STE 200
SANTA FE NM
87505-7602
US

IV. Provider business mailing address

PO BOX 26666
ALBUQEURQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-5000
  • Fax:
Mailing address:
  • Phone: 505-923-9770
  • Fax: 505-923-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2020-0150
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: