Healthcare Provider Details

I. General information

NPI: 1720348568
Provider Name (Legal Business Name): LELA THERESE GONZALES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 NE GLISAN ST STE BG05
PORTLAND OR
97213-2933
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-2392
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD173266
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD173266
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500693980
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
IdentifierP01547776
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerRR MEDICARE (PH&S)-PMG

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: