Basic Information
| Provider Information | |||||||||
| NPI: | 1720348568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | LELA | ||||||||
| MiddleName: | THERESE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4805 NE GLISAN ST | ||||||||
| Address2: | STE BG05 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972132933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032152392 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2012 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD173266 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD173266 | OR | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 500693980 | 05 | OR | MEDICAID | P01547776 | 01 | OR | RR MEDICARE (PH&S)-PMG | OTHER |