Provider Demographics
NPI:1205962933
Name:GONZALEZ, JORGE A (CPO)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 MAPLE DR W
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-3154
Mailing Address - Country:US
Mailing Address - Phone:516-270-3781
Mailing Address - Fax:
Practice Address - Street 1:1402 CASTLE HILL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4809
Practice Address - Country:US
Practice Address - Phone:718-824-3595
Practice Address - Fax:718-824-4404
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1744P3200X1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5437890001Medicare ID - Type Unspecified