Provider Demographics
NPI:1295997815
Name:GONZALEZ, GUSTAVO VIRGEN (MD)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:VIRGEN
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 1:11038 CAMARILLO ST UNIT 7
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-3542
Mailing Address - Country:US
Mailing Address - Phone:818-523-4079
Mailing Address - Fax:
Practice Address - Street 1:1600 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-3115
Practice Address - Country:US
Practice Address - Phone:818-896-0531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96103207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology