Provider Demographics
NPI:1497709091
Name:GONZALES, EMELITO (MD)
Entity Type:Individual
Prefix:
First Name:EMELITO
Middle Name:
Last Name:GONZALES
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 1:2 LAKE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-3542
Mailing Address - Country:US
Mailing Address - Phone:845-837-1388
Mailing Address - Fax:845-837-1389
Practice Address - Street 1:707 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2650
Practice Address - Country:US
Practice Address - Phone:845-695-5999
Practice Address - Fax:845-695-5832
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12543912085R0001X
NJ25MA034394002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00234868Medicaid
NJ2236303Medicaid
NY83S421Medicare ID - Type Unspecified
NJ2236303Medicaid