Provider Demographics
NPI:1639454978
Name:GONZALEZ, JOE
Entity Type:Individual
Prefix:
First Name:JOE
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 1:210 BEAR HILL RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1025
Mailing Address - Country:US
Mailing Address - Phone:781-890-9870
Mailing Address - Fax:
Practice Address - Street 1:210 BEAR HILL RD
Practice Address - Street 2:SUITE 400
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1025
Practice Address - Country:US
Practice Address - Phone:781-890-9870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH26169183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist