Provider Demographics
NPI:1912990342
Name:GONZALEZ, JOSE L (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
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 1:420 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3625
Mailing Address - Country:US
Mailing Address - Phone:570-621-5325
Mailing Address - Fax:570-621-5325
Practice Address - Street 1:420 SOUTH JACKSON STREET
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901
Practice Address - Country:US
Practice Address - Phone:570-621-5325
Practice Address - Fax:570-621-5325
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026695E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAD71163Medicare UPIN
PA101578Medicare ID - Type Unspecified