Provider Demographics
NPI:1326282518
Name:RAFAEL GONZALEZ DPM LLC
Entity Type:Organization
Organization Name:RAFAEL GONZALEZ DPM LLC
Other - Org Name:GREATER HARTFORD PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-263-7999
Mailing Address - Street 1:580 COTTAGE GROVE RD
Mailing Address - Street 2:STE 203
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3088
Mailing Address - Country:US
Mailing Address - Phone:860-263-7999
Mailing Address - Fax:860-216-0664
Practice Address - Street 1:580 COTTAGE GROVE RD STE 203
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3088
Practice Address - Country:US
Practice Address - Phone:860-263-7999
Practice Address - Fax:860-216-0664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000808213E00000X, 213ES0131X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU86144Medicare UPIN
480000972Medicare PIN