Provider Demographics
NPI:1083167746
Name:GONZALES, JOE ROBERT JR (OTD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:ROBERT
Last Name:GONZALES
Suffix:JR
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3537
Mailing Address - Country:US
Mailing Address - Phone:907-374-4911
Mailing Address - Fax:
Practice Address - Street 1:398 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3537
Practice Address - Country:US
Practice Address - Phone:907-374-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK113930225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist