Provider Demographics
NPI:1548526346
Name:GONZALEZ, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: MCMF - CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:657-241-3616
Mailing Address - Fax:
Practice Address - Street 1:31001 RANCHO VIEJO RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675
Practice Address - Country:US
Practice Address - Phone:949-661-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123045207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB219020Medicare PIN