MEDICARE: MICHELLE GONZALES M.D.

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	207Q00000X	Family Medicine Physician	A77417	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A77417	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1073539136
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE GONZALES M.D.

Provider Business Mailing Address
First Line	:	3601 VISTA WAY
Second Line	:	SUITE 201
City	:	OCEANSIDE
State	:	CA
Zip	:	92056-4559
Country	:	US
Telephone Number	:	760-639-1204
Fax Number	:	760-630-1252

Provider Business Practice Location Address
First Line	:	3601 VISTA WAY
Second Line	:	SUITE 201
City	:	OCEANSIDE
State	:	CA
Zip	:	92056-4559
Country	:	US
Telephone Number	:	760-639-1204
Fax Number	:	760-630-1252

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	09/10/2014

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Directions to “ MICHELLE GONZALES M.D.” Practice Location

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