Provider Demographics
NPI:1053466797
Name:GONZALES, HENRY (DPM)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10225A CAMDEN LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-5500
Mailing Address - Country:US
Mailing Address - Phone:708-790-1303
Mailing Address - Fax:
Practice Address - Street 1:2008 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-3767
Practice Address - Country:US
Practice Address - Phone:773-968-6942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005275213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-005275OtherLIC POD
IL016-005275OtherLIC POD