Provider Demographics
NPI:1154616357
Name:GONZALEZ, NINA (MD, MPH)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:10629 PORTO CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2014 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462-1607
Practice Address - Country:US
Practice Address - Phone:617-243-6467
Practice Address - Fax:617-243-6701
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA248917207R00000X
PAMD4553312083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine