Provider Demographics
NPI:1649247628
Name:GONZALEZ, EDWIN (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:GONZALEZ
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 1:2201 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1859
Mailing Address - Country:US
Mailing Address - Phone:516-572-6705
Mailing Address - Fax:516-572-5140
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:8TH FLOOR - PAVILLION
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1859
Practice Address - Country:US
Practice Address - Phone:516-572-6705
Practice Address - Fax:516-572-5140
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182992-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01839909Medicaid
NYG42774Medicare UPIN
NY4416H1Medicare PIN