Provider Demographics
NPI:1952623258
Name:GONZALEZ, JOSE MARIO
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:MARIO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 W FULLERTON AVE
Mailing Address - Street 2:UNIT 404
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2198
Mailing Address - Country:US
Mailing Address - Phone:773-244-3361
Mailing Address - Fax:
Practice Address - Street 1:5050 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-3009
Practice Address - Country:US
Practice Address - Phone:773-476-6323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-28
Last Update Date:2010-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.039540183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist