Provider Demographics
NPI:1023161684
Name:GONZALEZ, ENRIQUE JOSE (MD)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:JOSE
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 1:321 S MEDNIK AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-1839
Mailing Address - Country:US
Mailing Address - Phone:323-261-4706
Mailing Address - Fax:323-261-4124
Practice Address - Street 1:321 S MEDNIK AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022
Practice Address - Country:US
Practice Address - Phone:323-261-4706
Practice Address - Fax:323-261-4124
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74790208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG747490Medicaid
CA00G747901Medicaid
CAG74790Medicare PIN