Provider Demographics
NPI:1104869429
Name:GONZALES, BERNADETH TAGLE (MD)
Entity type:Individual
Prefix:
First Name:BERNADETH
Middle Name:TAGLE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 214TH ST SE STE 300
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-4418
Mailing Address - Country:US
Mailing Address - Phone:425-412-7200
Mailing Address - Fax:
Practice Address - Street 1:1909 214TH ST SE STE 300
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-4418
Practice Address - Country:US
Practice Address - Phone:425-412-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00047444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA225508OtherL & I NUMBER
WA8868622OtherMEDICARE NUMBER
WA1042878Medicaid
WA8495723Medicaid
WA8868622OtherMEDICARE NUMBER