Provider Demographics
NPI:1568453082
Name:GONZALEZ, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
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:BROAD AND VINE STS
Mailing Address - Street 2:MS 310
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19102
Mailing Address - Country:US
Mailing Address - Phone:215-762-4312
Mailing Address - Fax:215-762-8656
Practice Address - Street 1:BROAD AND VINE STS
Practice Address - Street 2:MS 310
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-762-4312
Practice Address - Fax:215-762-8656
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030810L2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C26036Medicare UPIN
1909Medicare ID - Type Unspecified