Provider Demographics
NPI:1669443859
Name:GONZALEZ, JAIME (DC)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10110 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-3948
Mailing Address - Country:US
Mailing Address - Phone:502-937-7995
Mailing Address - Fax:503-937-5560
Practice Address - Street 1:10110 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-3948
Practice Address - Country:US
Practice Address - Phone:502-937-7995
Practice Address - Fax:503-937-5560
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5135111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100072710Medicaid
KYK030550OtherMEDICARE PTAN