Provider Demographics
NPI:1073776928
Name:GONZAGA, TERESA A (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:A
Last Name:GONZAGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1035 KEPLER DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8320
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:2605 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4240
Practice Address - Country:US
Practice Address - Phone:920-288-8240
Practice Address - Fax:920-857-1488
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI691352086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery