Provider Demographics
NPI:1629516547
Name:GONZALEZ, WILLY
Entity Type:Individual
Prefix:
First Name:WILLY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:609-677-7003
Mailing Address - Fax:
Practice Address - Street 1:200 WHITE PLAINS RD FL 4
Practice Address - Street 2:
Practice Address - City:TARRYTOWN
Practice Address - State:NY
Practice Address - Zip Code:10591-5838
Practice Address - Country:US
Practice Address - Phone:888-636-7840
Practice Address - Fax:267-479-1321
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-11
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11472800207QS0010X
NY316950207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine