Basic Information
| Provider Information | |||||||||
| NPI: | 1992786487 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28949 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937298949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592284200 | ||||||||
| FaxNumber: | 5592443920 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 W HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936120204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593246200 | ||||||||
| FaxNumber: | 5593246280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G55847 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | G55847 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00G558470 | 05 | CA | MEDICAID | 77040368493612B010 | 01 | CA | CHAMPUS | OTHER | 00G558470 | 01 | CA | BLUE CROSS/BLUE SHIELD | OTHER | 110125078 | 01 | CA | RAILROAD MEDICARE | OTHER |