Provider Demographics
NPI:1194780627
Name:DEBELEN-GONZALES, RENELLIE (MD)
Entity type:Individual
Prefix:
First Name:RENELLIE
Middle Name:
Last Name:DEBELEN-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 1:2851 S AVE B STE 32
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7726
Mailing Address - Country:US
Mailing Address - Phone:928-783-5828
Mailing Address - Fax:928-373-9699
Practice Address - Street 1:2851 S AVE B STE 32
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7726
Practice Address - Country:US
Practice Address - Phone:928-783-5828
Practice Address - Fax:928-373-9699
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27259207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ459158Medicaid
AZZ104921Medicare PIN
G93974Medicare UPIN