Provider Demographics
NPI:1225170749
Name:GONZALEZ, CARLOS ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ANTONIO
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 1:2834 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618
Mailing Address - Country:US
Mailing Address - Phone:773-772-1139
Mailing Address - Fax:773-772-9260
Practice Address - Street 1:4311 S KEDVALE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4004
Practice Address - Country:US
Practice Address - Phone:773-552-1139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036040539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D89277Medicare UPIN
IL492730Medicare ID - Type Unspecified