Provider Demographics
NPI:1346459757
Name:GONZALEZ, JOSE E (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:E
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 1:1380 PROGRESS WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6499
Mailing Address - Country:US
Mailing Address - Phone:410-795-4020
Mailing Address - Fax:410-795-2733
Practice Address - Street 1:1380 PROGRESS WAY STE 110
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6499
Practice Address - Country:US
Practice Address - Phone:410-795-4020
Practice Address - Fax:410-795-2733
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD030953174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD71163Medicare UPIN