Provider Demographics
NPI:1790305886
Name:GONZALEZ, SIMON PETER
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:PETER
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 1:293 GRAND AVE APT 3L
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-1245
Mailing Address - Country:US
Mailing Address - Phone:718-314-9306
Mailing Address - Fax:
Practice Address - Street 1:102 PILLING ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-1610
Practice Address - Country:US
Practice Address - Phone:718-602-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program