Basic Information
| Provider Information | |||||||||
| NPI: | 1366425886 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CELIS | ||||||||
| FirstName: | GONZALO | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 N FORBES BLVD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857451412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206225912 | ||||||||
| FaxNumber: | 5207912246 | ||||||||
| Practice Location | |||||||||
| Address1: | 395 N SILVERBELL RD | ||||||||
| Address2: | SUITE 355 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857452656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206225912 | ||||||||
| FaxNumber: | 5207912246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 07/21/2011 | ||||||||
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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 | 14913 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 239873 | 05 | AZ | MEDICAID |