Provider Demographics
NPI:1013001999
Name:JUAN A GONZALEZ MD PA
Entity Type:Organization
Organization Name:JUAN A GONZALEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-795-9080
Mailing Address - Street 1:3196 KENNEDY BLVD
Mailing Address - Street 2:MAILBOX 16A
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-2436
Mailing Address - Country:US
Mailing Address - Phone:201-795-9080
Mailing Address - Fax:201-795-9434
Practice Address - Street 1:3196 KENNEDY BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-2436
Practice Address - Country:US
Practice Address - Phone:201-795-9080
Practice Address - Fax:201-795-9434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA4258800208600000X
NJ25MA07273600208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0003875Medicaid
NJ0003875Medicaid