Provider Demographics
NPI:1679132112
Name:GONZALEZ, HECTOR SALVADOR (IDC)
Entity Type:Individual
Prefix:
First Name:HECTOR
Middle Name:SALVADOR
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BUSHNELL ST
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 BUSHNELL ST
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3306
Practice Address - Country:US
Practice Address - Phone:787-431-4867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman