Provider Demographics
NPI:1609302900
Name:GONZALEZ, CLEMEN O (MD)
Entity Type:Individual
Prefix:
First Name:CLEMEN
Middle Name:O
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 1:1649 N PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-5207
Mailing Address - Country:US
Mailing Address - Phone:773-278-6868
Mailing Address - Fax:773-278-6922
Practice Address - Street 1:1649 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-5207
Practice Address - Country:US
Practice Address - Phone:773-278-6868
Practice Address - Fax:773-278-6922
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.070078390200000X
IL036.152519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program