Provider Demographics
NPI:1174636229
Name:GONZALEZ, MARCO A (MD)
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:A
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 1:1400 E PALOMAR ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1800
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:619-397-3386
Practice Address - Street 1:1400 E PALOMAR ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91913-1800
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:619-397-3386
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76308207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A763080Medicaid
CA00A763080Medicaid
CAWA76308AMedicare ID - Type Unspecified