Provider Demographics
NPI:1245848506
Name:GONZALES, ANTON R
Entity type:Individual
Prefix:
First Name:ANTON
Middle Name:R
Last Name:GONZALES
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 1:28431 CUNNINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-3427
Mailing Address - Country:US
Mailing Address - Phone:248-464-7132
Mailing Address - Fax:
Practice Address - Street 1:2295 CHENE, DETROIT, MI 48207
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207
Practice Address - Country:US
Practice Address - Phone:313-923-5816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004845225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant