Provider Demographics
NPI:1588730162
Name:JAIME GONZALEZ, M.D., INC.
Entity type:Organization
Organization Name:JAIME GONZALEZ, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-622-3353
Mailing Address - Street 1:350 VINTON AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3000
Mailing Address - Country:US
Mailing Address - Phone:909-622-3353
Mailing Address - Fax:909-622-3833
Practice Address - Street 1:350 VINTON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3000
Practice Address - Country:US
Practice Address - Phone:909-622-3353
Practice Address - Fax:909-622-3833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87328207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I09682Medicare UPIN