Provider Demographics
NPI:1255504627
Name:GONZALES, JAMES JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JOSEPH
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 E GRANT ST
Mailing Address - Street 2:STE 211
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3368
Mailing Address - Country:US
Mailing Address - Phone:309-833-3706
Mailing Address - Fax:
Practice Address - Street 1:515 E GRANT ST
Practice Address - Street 2:STE 211
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3368
Practice Address - Country:US
Practice Address - Phone:309-833-3706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-08
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054734208600000X
CAA75715208600000X
IL036136309208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery