Provider Demographics
NPI:1235607011
Name:GONZALES, JOSE LUIS (CO,BOCO)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:GONZALES
Suffix:
Gender:M
Credentials:CO,BOCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20225 SUTTER CREEK DR APT 208
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12075 CORPORATE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-2664
Practice Address - Country:US
Practice Address - Phone:262-643-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist