Basic Information
| Provider Information | |||||||||
| NPI: | 1629171046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 CADILLAC DRIVE | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958255480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169202082 | ||||||||
| FaxNumber: | 9169201430 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 CADILLAC DRIVE | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958255480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169202082 | ||||||||
| FaxNumber: | 9169201430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2002-0166 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 300920YR41 | 01 | NM | MEDICARE | OTHER | 34400567 | 05 | NM | MEDICAID |