Provider Demographics
NPI:1780790568
Name:GONZALEZ, MARCIA M (MD)
Entity type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4254
Mailing Address - Country:US
Mailing Address - Phone:201-866-6770
Mailing Address - Fax:201-868-6771
Practice Address - Street 1:8100 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4254
Practice Address - Country:US
Practice Address - Phone:201-866-6770
Practice Address - Fax:201-868-6771
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04299100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1749706Medicaid
NJ1749706Medicaid
NJ213862P4PMedicare PIN