Basic Information
| Provider Information | |||||||||
| NPI: | 1043401086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ GONZALEZ | ||||||||
| FirstName: | HUMBERTO | ||||||||
| MiddleName: | CESAR | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | DEPT # 457 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015169183 | ||||||||
| FaxNumber: | 9015168993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1265 UNION AVE | ||||||||
| Address2: | SUITE 184 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015169183 | ||||||||
| FaxNumber: | 9015168993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301089991 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 107128 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 56890 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 51261 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RT0003X | 51261 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Transplant Hepatology |
ID Information
| ID | Type | State | Issuer | Description | Q008639 | 05 | TN | MEDICAID | 04122575 | 05 | MS | MEDICAID | 206119001 | 05 | AR | MEDICAID | 6025474 | 01 | TN | BCBS | OTHER |