Provider Demographics
NPI:1851509392
Name:GONZALES MEDICAL GROUP INC
Entity type:Organization
Organization Name:GONZALES MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:CARMEN
Authorized Official - Last Name:PONZIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-675-3601
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:133 FOURTH STREET
Mailing Address - City:GONZALES
Mailing Address - State:CA
Mailing Address - Zip Code:93926-0646
Mailing Address - Country:US
Mailing Address - Phone:831-675-3601
Mailing Address - Fax:
Practice Address - Street 1:133 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:CA
Practice Address - Zip Code:93926
Practice Address - Country:US
Practice Address - Phone:831-675-3601
Practice Address - Fax:831-675-3966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7032530Medicaid
CARHM53884GMedicaid
CAA18653Medicare UPIN
CARHM53884GMedicaid
CAZZZ20705ZMedicare PIN