MEDICARE: MIGUEL GONZALES M D PROF CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1053464602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIGUEL GONZALES M D PROF CORP

Provider Business Mailing Address
First Line	:	9030 W SAHARA AVE # 260
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5744
Country	:	US
Telephone Number	:	702-321-5293
Fax Number	:	702-463-1507

Provider Business Practice Location Address
First Line	:	9030 W SAHARA AVE # 260
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-5744
Country	:	US
Telephone Number	:	702-321-5293
Fax Number	:	702-463-1507

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MIGUEL A GONZALEZ
Credential	:	MD
Telephone Number	:	702-233-3191

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	06/23/2010

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