Provider Demographics
NPI:1083755730
Name:GONZALEZ, JOHN (BS,PH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:BS,PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SUN VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2137
Mailing Address - Country:US
Mailing Address - Phone:631-261-4124
Mailing Address - Fax:
Practice Address - Street 1:7 SUN VALLEY CT
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2137
Practice Address - Country:US
Practice Address - Phone:631-261-4124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY39968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00396745Medicaid
NY0242650001Medicare ID - Type Unspecified