Provider Demographics
NPI:1699278366
Name:GONZALES, JOHN CARLOS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CARLOS
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7873 S CHADBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5806
Mailing Address - Country:US
Mailing Address - Phone:801-244-3280
Mailing Address - Fax:
Practice Address - Street 1:7873 S CHADBOURNE DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-5806
Practice Address - Country:US
Practice Address - Phone:801-244-3280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR58639857OtherBLUE CROSS BLUE SHIELD