Provider Demographics
NPI:1205244688
Name:GONZALEZ, IRVING
Entity type:Individual
Prefix:
First Name:IRVING
Middle Name:
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 1:2604 S EMERALD AVE
Mailing Address - Street 2:APARTMENT C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2525
Mailing Address - Country:US
Mailing Address - Phone:847-791-0240
Mailing Address - Fax:
Practice Address - Street 1:1921 DAVIS AVE
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IN
Practice Address - Zip Code:46394-1820
Practice Address - Country:US
Practice Address - Phone:219-659-3522
Practice Address - Fax:219-554-4571
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002219A2255A2300X
IL0960035432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer