Provider Demographics
NPI:1093214645
Name:GONZALEZ, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-3650
Mailing Address - Country:US
Mailing Address - Phone:630-515-1185
Mailing Address - Fax:
Practice Address - Street 1:4905 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-3650
Practice Address - Country:US
Practice Address - Phone:630-515-1185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3000244376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker