Basic Information
| Provider Information | |||||||||
| NPI: | 1518981281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ORLANDO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 E ELVIRA RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857067124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208747400 | ||||||||
| FaxNumber: | 5208743425 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 E AJO WAY | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857136204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208747400 | ||||||||
| FaxNumber: | 5208743425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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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 | 2084N0400X | 35610 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD462889 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1034764370009 | 05 | PA | MEDICAID | P00322978 | 01 | AZ | RR MEDICARE | OTHER | 112240 | 05 | AZ | MEDICAID |