Provider Demographics
NPI:1972815397
Name:JOSE A. GONZALEZ DC PC
Entity Type:Organization
Organization Name:JOSE A. GONZALEZ DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:631-219-1706
Mailing Address - Street 1:7 MAYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-1704
Mailing Address - Country:US
Mailing Address - Phone:631-219-1706
Mailing Address - Fax:631-922-8878
Practice Address - Street 1:1805 5TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1761
Practice Address - Country:US
Practice Address - Phone:631-219-1706
Practice Address - Fax:631-922-8878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYXOO8699-1261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center