Provider Demographics
NPI:1629248562
Name:GONZAGA, JONATHAN ORIO (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ORIO
Last Name:GONZAGA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14-25 PLAZA RD
Mailing Address - Street 2:S-3-1
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3546
Mailing Address - Country:US
Mailing Address - Phone:201-797-2050
Mailing Address - Fax:201-797-2051
Practice Address - Street 1:14-25 PLAZA RD
Practice Address - Street 2:S31
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3546
Practice Address - Country:US
Practice Address - Phone:201-797-2050
Practice Address - Fax:201-797-2051
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028580174400000X
NJ40QA01303200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01303200OtherLICENSE
NY028580OtherLICENSE