Provider Demographics
NPI:1467750091
Name:GONZALEZ, OLGA BEATRIZ (LAC, MSTOM)
Entity Type:Individual
Prefix:MS
First Name:OLGA
Middle Name:BEATRIZ
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W 16TH ST
Mailing Address - Street 2:#3F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-6165
Mailing Address - Country:US
Mailing Address - Phone:212-989-6345
Mailing Address - Fax:
Practice Address - Street 1:200 W 16TH ST
Practice Address - Street 2:#3F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-6165
Practice Address - Country:US
Practice Address - Phone:212-989-6345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004276171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
171100000XOtherPROVIDER IDENTIFICATION CODE