Provider Demographics
NPI:1366514655
Name:GONZALEZ, EDGARDO (MD)
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
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:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-0277
Mailing Address - Country:US
Mailing Address - Phone:714-994-5290
Mailing Address - Fax:714-994-8090
Practice Address - Street 1:6301 BEACH BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2840
Practice Address - Country:US
Practice Address - Phone:714-994-5290
Practice Address - Fax:714-994-8090
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G536930Medicaid
CAGR0099930Medicaid
CAWG53693LMedicare ID - Type UnspecifiedRENDERING PROVIDER ID
CAW18427Medicare ID - Type UnspecifiedMEDICARE GROUP
CA00G536930Medicaid