Healthcare Provider Details

I. General information

NPI: 1043208218
Provider Name (Legal Business Name): DAVID MANUEL GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HOSPITAL LN
AFTON WY
83110-9409
US

IV. Provider business mailing address

901 ADAMS ST
AFTON WY
83110-9621
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-5824
  • Fax:
Mailing address:
  • Phone: 307-885-5824
  • Fax: 307-885-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberM-9795
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number26748
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4237A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: