Provider Demographics
NPI:1821431909
Name:GONZALES, KAITLIN DICKERT (DPM)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:DICKERT
Last Name:GONZALES
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:ELYSE
Other - Last Name:DICKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:121 CENTER GROVE RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-4453
Mailing Address - Country:US
Mailing Address - Phone:973-366-1016
Mailing Address - Fax:
Practice Address - Street 1:121 CENTER GROVE RD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-4453
Practice Address - Country:US
Practice Address - Phone:973-366-1016
Practice Address - Fax:973-366-5925
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00327900213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist