Provider Demographics
NPI:1114306537
Name:GONZALEZ, JAIME (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1969 WEST HART RD
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2283
Mailing Address - Country:US
Mailing Address - Phone:608-364-5011
Mailing Address - Fax:608-364-5452
Practice Address - Street 1:1969 WEST HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2283
Practice Address - Country:US
Practice Address - Phone:608-364-5011
Practice Address - Fax:608-364-5452
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73854207RI0200X
390200000X
WI73854-20207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1114306537Medicaid