Provider Demographics
NPI:1568459626
Name:GONZALES, REYNALDO NOVAK (MD)
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:NOVAK
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 1:350 W COLUMBIA ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-1782
Mailing Address - Country:US
Mailing Address - Phone:812-422-3254
Mailing Address - Fax:812-426-6388
Practice Address - Street 1:350 W COLUMBIA ST
Practice Address - Street 2:SUITE 420
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1782
Practice Address - Country:US
Practice Address - Phone:812-422-3254
Practice Address - Fax:812-426-6388
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054764A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64038029Medicaid
IN200344150Medicaid
IN300121222OtherRAILROAD MEDICARE
IN300121232OtherRAILROAD MEDICARE
KY64038029Medicaid
KY64038029Medicaid
ING96728Medicare UPIN
KY64038029Medicaid