Provider Demographics
NPI:1912290149
Name:GONZALEZ, EDNA M
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 MACON ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4522
Mailing Address - Country:US
Mailing Address - Phone:217-872-7268
Mailing Address - Fax:219-872-2224
Practice Address - Street 1:8865 W 400 N
Practice Address - Street 2:#115
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9222
Practice Address - Country:US
Practice Address - Phone:219-872-7268
Practice Address - Fax:219-872-2224
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant