MEDICARE: MR. JAIME MARCOS GONZALES M.S., CGC

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	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1780662064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAIME MARCOS GONZALES M.S., CGC

Provider Business Mailing Address
First Line	:	3697 CAMINITO CARMEL LNDG
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-2514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6507 MISSION GORGE RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-2306
Country	:	US
Telephone Number	:	619-528-6471
Fax Number	:

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

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	07/08/2007

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