Provider Demographics
NPI:1851349997
Name:GONZALEZ, RAFAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 COTTAGE GROVE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-3088
Mailing Address - Country:US
Mailing Address - Phone:860-263-7999
Mailing Address - Fax:860-216-0664
Practice Address - Street 1:580 COTTAGE GROVE RD STE 203
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3088
Practice Address - Country:US
Practice Address - Phone:860-263-7999
Practice Address - Fax:860-216-0664
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000808213ES0131X, 213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT480000972Medicare PIN
CTC03537Medicare PIN