Provider Demographics
NPI:1285296657
Name:GONZALES, MICHAEL JOSE (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSE
Last Name:GONZALES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14153 VICTORY BLVD APT 212
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-1941
Mailing Address - Country:US
Mailing Address - Phone:847-736-5183
Mailing Address - Fax:
Practice Address - Street 1:4640 ADMIRALTY WAY STE 420
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6617
Practice Address - Country:US
Practice Address - Phone:424-526-5151
Practice Address - Fax:424-835-6475
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2967222251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic