Provider Demographics
NPI:1043401086
Name:GONZALEZ GONZALEZ, HUMBERTO CESAR (MD)
Entity type:Individual
Prefix:
First Name:HUMBERTO
Middle Name:CESAR
Last Name:GONZALEZ GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:139-167-1783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56890207RG0100X
TN51261207RG0100X, 207RT0003X
MI4301089991207RG0100X, 207R00000X
MN107128207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6025474OtherBCBS
MS04122575Medicaid
AR206119001Medicaid
TNQ008639Medicaid
AR206119001Medicaid