Provider Demographics
NPI:1295040855
Name:GONZALEZ, THERESE FERMO (MD)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:FERMO
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:THERASE ANGELICA
Other - Middle Name:V
Other - Last Name:FERMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-8099
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4502
Practice Address - Country:US
Practice Address - Phone:616-685-8500
Practice Address - Fax:616-685-8910
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD8816207R00000X
MI4301095835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6007610Medicaid
SDP1282353OtherRR MEDICARE
SDS107635Medicare PIN