Provider Demographics
NPI:1164856704
Name:GONZALEZ, GRANT WILSON (DPM)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:WILSON
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 MONTVALE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-5359
Mailing Address - Country:US
Mailing Address - Phone:217-787-2700
Mailing Address - Fax:217-787-2715
Practice Address - Street 1:2921 MONTVALE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5359
Practice Address - Country:US
Practice Address - Phone:217-787-2700
Practice Address - Fax:217-787-2715
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001231213ES0103X
IL016005651213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005651OtherSTATE OF ILLINOIS
IL016005651OtherSTATE OF ILLINOIS