Provider Demographics
NPI:1093732455
Name:GONZALO, JOSE ANTHONY (BSPH)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:ANTHONY
Last Name:GONZALO
Suffix:
Gender:M
Credentials:BSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 POPLAR DR
Mailing Address - Street 2:SHADY ACRES
Mailing Address - City:KULPMONT
Mailing Address - State:PA
Mailing Address - Zip Code:17834-1906
Mailing Address - Country:US
Mailing Address - Phone:570-373-1035
Mailing Address - Fax:570-373-1035
Practice Address - Street 1:49 S OAK ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:PA
Practice Address - Zip Code:17851-2164
Practice Address - Country:US
Practice Address - Phone:570-339-5900
Practice Address - Fax:570-339-5900
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP-026335L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist