Provider Demographics
NPI:1699091892
Name:BARRAZA, GONZALO (MD)
Entity type:Individual
Prefix:
First Name:GONZALO
Middle Name:
Last Name:BARRAZA
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 413037
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84141-3037
Mailing Address - Country:US
Mailing Address - Phone:801-213-3900
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0100
Practice Address - Country:US
Practice Address - Phone:801-581-2507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT8137232-1205207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program