Provider Demographics
NPI:1952384174
Name:GONZALEZ, WANDA I (MD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:I
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-889-8520
Mailing Address - Fax:617-889-8571
Practice Address - Street 1:151 EVERETT AVE
Practice Address - Street 2:CHELSEA HEALTHCARE CENTER
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-1807
Practice Address - Country:US
Practice Address - Phone:617-889-8520
Practice Address - Fax:617-889-8571
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2014-02-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA79774208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA079774OtherTUFTS HEALTH PLAN
MAJ30930OtherBCBS
MA3130886Medicaid
MAJ30930Medicare PIN
MAJ30930OtherBCBS